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THE CASE HISTORY SERIES 

PRINCIPLES OF MEDICAL TREATMENT 

GEORGE CHEEVER SHATTUCK, M.D. 
Fifth Edition, revised and enlarged 

CASE HISTORIES IN MEDICINE 

RICHARD C. CABOT, M.D. 

Third edition, revised and enlarged 

DISEASES OF CHILDREN 

JOHN LOVETT MORSE, M.D. 
Third edition, revised and enlarged. Presented in two hundred Case Histories 

ONE HUNDRED SURGICAL PROBLEMS 

JAMES G. MUMFORD, M.D. 
Second Printing 

WOUNDS OF THE LUNG AND PLEURA 

PROFESSOR EUGENIO MORELLI 

Translated by Drs. Lincoln Davis and Frederick C. Irving. 

Octavo. 30 Plates. Sixty Case Histories 

CASE HISTORIES IN NEUROLOGY 

E. W. TAYLOR, M.D. 
Second Printing 

CASE HISTORIES IN OBSTETRICS 

ROBERT L. DeNORMANDIE, M.D. 

Second Edition 

DISEASES OF WOMEN 

CHARLES M. GREEN, M.D. 

Second Edition. Presented in one hundred and seventy-three Case Histories 

PULMONARY TUBERCULOSIS 

EDWARD O. OTIS, M.D. 

Second Edition, revised and enlarged 

NEUROSYPHILIS 
MODERN SYSTEMATIC DIAGNOSIS AND TREATMENT 

Presented in one hundred and thirty-seven Case Histories 
E. E. SOUTHARD, M.D., SC.D., and H. C. SOLOMON, M.D. 

Being Monograph Number Two of the Psychopathic Department of the Boston 

State Hospital, Massachusetts. (Monograph Number One was A Point Scale 

for Measuring Mental Ability by Robert M. Terkes, James W. Bridges and Rose 

S. Hardwick. Published by 'Warwick and York. Baltimore 1915.) 

SHELL SHOCK AND OTHER NEUROPSYCHIATRY PROBLEMS 

Presented in five hundred and eighty-nine Case Histories 

E. E. SOUTHARD, M.D., SC.D. 

Being Monograph Number Three of the Psychopathic Department of the Boston 

State Hospital 



PULMONARY 
TUBERCULOSIS 

A HANDBOOK FOR STUDENTS 
AND PRACTITIONERS 

BY 

EDWARD O. OTIS, A.B., M.D. 

Professor of Pulmonary Diseases and Climatology, Tufts College 
Medical School, Boston; Formerly Visiting and Consulting 
Physician to the Massachusetts State Sanatorium (Rut- 
land) ; Fellow and Former President of the American 
Climatological and Clinical Association; Corre- 
sponding Member of the International Tuber- 
culosis Institute; Consulting Physician to 
the Boston Dispensary, Tuberculosis 
Department; Major, M. R. C, 
U. S. A. 

SECOND EDITION 



" This is the malady which the ancients 
did call tabes, or the wasting disease, and 
some do name consumption." 

Master Giles Firmin 



BOSTON 

W. M. LEONARD, Publisher 

1920 






Copyright, 1920 
By W. M. LEONARD^ 



JUL 25 71 

©CLA622159 



3 



TO THE LATE 

FREDERICK IRVING KNIGHT, A.M., M.D. 

A man of profound knowledge and great 

experience in Tuberculosis 

Teacher, Writer, and Worker in the 

Prevention of the Disease 



PREFACE TO THE SECOND EDITION. 

In this edition the text has been carefully revised and 
various additions have been made. A new chapter has been 
added on the "Examination of Soldiers for Tuberculosis," 
embracing the very excellent methods given by Colonel 
George E. Bushnell, the head of the Department of Tuber- 
culosis in the War. The "Essential Points'' in the physical 
examination by Major Stoll are also included. There is so 
much of great value in these standardized methods of exami- 
nation of the lungs adopted for the Army that the author 
believes they will be almost equally valuable in civil life. 
The "Diagnostic Standards" of the National Tuberculosis 
Association, prepared by the Diagnostic Standard Com- 
mittee of the "Framingham Community Health and Tuber- 
culosis Demonstration," both for adults and children, are 
included in this edition, admirable both for their succinct- 
ness and as embodying the combined wisdom of well-known 
specialists. Further and free use has been made of the very 
suggestive aphorisms and theses, both for diagnosis, prog- 
nosis and treatment of Dr. Lawrason Brown of Saranac 
Lake, published in the "American Review of Tuberculosis," 
Vol. I., No. 4, 191 7, and the author desires to acknowledge 
especial indebtedness to Dr. Brown for the same. Such 
brief and dogmatic statements remain in one's memory 
when longer ones are forgotten. 

A brief account of the "Framingham Health and Tuber- 
culosis Demonstration" has been given, an experiment which 
has excited nation-wide interest and which is a model for 
other communities in dealing with Tuberculosis. 

Many new case histories have been added, covering 
the various phases of the subject, such as diagnosis, differ- 
ential diagnosis, tuberculosis in children, artificial pneumo- 
thorax and treatment. Such illustrative cases drawn from 



actual experience are the nearest approach to the real clinic, 
and illumine the text as nothing else can do. The author 
wishes to express his obligations to Dr. H. D. Chadwick 
and Dr. Roy Morgan, of the Massachusetts State Sana- 
torium at Westfield, for their kindness in furnishing him 
with cases of tuberculosis in children. 

In the chapter upon the "History of Tuberculosis," an 
account of Dr. Trudeau with a portrait has been added. No 
history of the progress of the study and treatment of tuber- 
culosis could, in this country at least, be complete without 
reference to this great pioneer in sanatorium treatment and 
in the investigation of the many problems connected with 
the disease. The author desires again to state that this book 
is but a manual, not a treatise, upon the subject. It is but a 
handbook with many case histories. From the numerous 
appreciative communications received, however, he is led 
to believe that it may be of service to the busy general prac- 
titioner, as well as the student, who has but limited time to 
devote to any one subject. 

It is the family physician who first sees the majority of 
the actual or suspected cases of pulmonary tuberculosis, 
and it is the hope of the author that this manual may aid 
him in making a reasonably early diagnosis and in applying 
the correct methods of treatment. 

E. O. O. 
Boston, 1920. 



CONTENTS 



•CHAPTER PAGE 

I ANATOMY AND PHYSIOLOGY . . . .11 
II THE HISTORY OF TUBERCULOSIS ... 26 

III PATHOLOGY AND BACTERIOLOGY . . . .35 

IV DIAGNOSIS 50 

V DIAGNOSIS (Continued) 67 

VI THE EXAMINATION OF SOLDIERS FOR TU- 
BERCULOSIS 93 

VII PROGNOSIS 100 

VIII TREATMENT no 

IX ESPECIAL METHODS OF TREATMENT . . 129 
X TREATMENT OF SPECIAL SYMPTOMS . . 135 

XI TUBERCULOSIS IN CHILDREN .... 153 

XII CLIMATE IN THE TREATMENT OF TUBER- 
CULOSIS 164 

XIII PROPHYLAXIS . 173 

3aV AFTERCARE AND MARRIAGE .... 180 

XV CASES . .185 



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CHAPTER I 

ANATOMY AND PHYSIOLOGY 

"Anatomy studies the organism in space, physiology studies it 
also in time." O. W . Holmes. 

In order to study intelligently the disease of any organ, a 
knowledge of its normal anatomy and topographical rela- 
tions, and its physiological function is obviously essential. 
Although this knowledge as applied to the lungs and their 
surroundings is supposed to have been already obtained in 
the courses upon anatomy and physiology, a brief review 
in this connection will not be without value in the further 
study of this subject. 

The Bony Framework of the Chest 

The lungs are contained in the bony framework of the 
chest which serves both as a protecting shield for the en- 
closed organs and as a mechanical device in conjunction with 
the respiratory muscles for producing the movements of 
respiration. 

This framework (Fig.i) is composed of the thoracic spine, 
to the bodies and transverse processes of which are attached 
the ribs, and the sternum, to which the ribs are united by 
cartilages. The thoracic spine consists of twelve thoracic 
vertebrae, and has a backwork convexity. The ribs, some- 
what circular in shape, are attached to the spine with vary- 
ing degrees of obliquity, but all, however, slope downward, 
outward and forward. 

Movement of the Ribs 

The ribs are articulated with the vertebrae in such a way 
that they form a sort of hinge of limited motion so that in 
the movements of respiration they swing on the fixed spine, 
up and down, and when elevated in the act of respiration 

II 



12 PULMONARY TUBERCULOSIS 

they push the sternum forward and thus increase the antero- 
posterior diameter of the chest, and at the same time the 
intercostal spaces are widened. Another motion also takes 
place when the ribs rise ; they describe a rotary motion out- 
ward around an imaginary axis which joins their two ex- 
tremities, and thus the transverse diameter of the chest is 
increased. 

Intercostal Spaces 
The intercostal spaces differ in size, being wider between 
the upper ribs than the lower. The second, third, tenth, 
and eleventh interspaces are the widest, and the widest part 
of each individual space is near the anterior part of the ribs. 
These spaces are closed by the intercostal muscles. Lying 
in a sort of gutter under the rib, at its lower border, are the 
intercostal artery, vein and nerve; in aspirating the chest, 
consequently, the arm on the affected side should be brought 
forward with the hand placed on the opposite shoulder so 
as to widen the interspace, and the aspirator needle thrust 
in at right angles close to the upper margin of the rib so as 
to avoid wounding these vessels. 

Counting the Ribs 

It is often necessary to count the ribs and it is sometimes 
difficult to do so directly, so that it is helpful to have some 
landmarks. The following are given by Holden: 

(a) "The angle of Ludovici, formed by the manubrium 
and gladiolus, is at the second rib." 

(b) "The nipple of the male is placed, in the great ma- 
jority of cases, between the fourth and fifth rib." 

(c) "The lower external border of the pectoralis major 
corresponds with the direction of the fifth rib." 

(d) "A line drawn horizontally from the nipple round the 
chest cuts the sixth intercostal space midway between the 
sternum and the spine." (This is a useful guide in tapping 
the chest.) 

(e) "When the arm is raised the highest visible digita- 
tion of the serratus magnus corresponds with the sixth rib, 
the digitations below this correspond respectively with the 
seventh and eighth ribs." 



ANATOMY AND PHYSIOLOGY 1 3 

(f) "The scapula lies on the ribs from the second to the 
seventh inclusive." 

(g) "The eleventh and twelfth ribs can be felt even in 
corpulent persons outside the erector spinae, sloping down- 
ward." 

(h) "One should remember the fact that the sternal end 
of each rib lies on a lower plane than its corresponding ver- 
tebra"; for instance, a line drawn horizontally backward 
from the middle of the third costal cartilage, at its junction 
with the sternum, to the spine, would touch the body not of 
the third dorsal vertebra but of the sixth. Again, the end 
of the sternum would be on about the level of the tenth 
dorsal vertebra. Much latitude must be allowed here for 
variation in the length of the sternum, especially in women." 

Diaphragm 

The base of the thoracic cavity is closed by the diaphragm, 
a dome-shaped muscle attached to the ensiform cartilage in 
front, to the cartilages and bony portions of the sixth and 
seventh inferior ribs on each side, and behind to two apo- 
neurotic arches and to the lumbar vertebrae. 

The diaphragm acts actively in conjunction with the inter- 
costal muscles in inspiration, while in expiration it becomes 
passive and is pushed up by the action of the abdominal 
muscles. By the contraction of the diaphragm in inspira- 
tion the chest is enlarged in its vertical direction. When 
the chest has become very rigid, or when the intercostal 
muscles are paralyzed, the diaphragm becomes the chief 
or only muscle of respiration. Also in ordinary tranquil 
breathing of the sedentary person this muscle does most of 
the work of respiration (abdominal respiration), as can be 
readily observed in watching the chest of a person at rest. 
Interference with the free movement of the diaphragm by 
a distended stomach or fluid in the peritoneum causes 
dyspnoea. No other muscle in the body, except the heart 
muscle, works more unceasingly than the diaphragm. Day 
and night, from birth to death, with only periods of rest of 
seconds, this faithful muscle does its duty. It is a very 
powerful muscle, and Campbell speaks of a man whom he 



14 PULMONARY TUBERCULOSIS 

knew who could move a grand piano by means of it. In 
forced inspiration the diaphragm is displaced downward 
three and one-half inches, which can be determined by the 
extension of resonance on percussion. The fluoroscope and 
the "Litten's phenomenon" indicate visibly the movements 
of the diaphragm. In early pulmonary tuberculosis the ex- 
cursion of the diaphragm is diminished on the affected side, 
as can be demonstrated by the fluoroscope. I do not, how- 
ever, consider this a very important diagnostic sign. 

The Thoracic Cavity and Pleurae 
The top of the thoracic cavity is shut in by the muscles 
about the neck. The interior of the cavity is lined by the 
pleurae, an exceedingly delicate serous membrane whose 
chief function is to enable the lungs to expand equally in all 
directions without friction. 

When pleural adhesions occur from inflammation of the 
pleurae, this free movement of the lungs is impeded, and this 
may be one reason why the apices of the lungs are so prone 
to tubercular infection; hence, as Campbell points out, "those 
with pleuritic adhesions should frequently resort to costal 
breathing." When the pleurae are normal, they are smooth 
and frictionless, and their inner surface is constantly lubri- 
cated with the serous fluid, so that the two layers slide freely 
upon each other and the movement of the lungs in respira- 
tion causes no sensation; if, however, the pleurae become 
roughened by inflammation, one experiences a "pleuritic 
pain" on breathing, and hence the reason for strapping the 
chest over the affected side to restrict the respiratory move- 
ment and thus lessen the pain. 

There is a right and left pleura separated by a space called 
the mediastinum which contains the heart and great vessels. 
Each pleura is two-fold, an outer parietal layer which is 
thick and feebly adherent to the inner wall of the chest 
throughout its entire extent and reflected upon the superior 
surface of the diaphragm below, and above extending 
through the upper opening of the thorax into the neck; and 
an inner or visceral layer which is extremely delicate and 
very transparent. It is very adherent to the lungs and in- 




Fig. 3. The Left Luns 



ANATOMY AND PHYSIOLOGY 1 5 

vests them completely, dipping to the bottom of the fissures 
which divide the lungs into lobes. 

Cavity of the Pleura 

The interspace between the two layers of the pleura is 
called the cavity of the pleura, which normally is closed, 
the parietal and visceral layers being in apposition. When, 
however, an effusion occurs the two layers are separated by 
the fluid, and when also the operation of artificial pneumo- 
thorax is performed the gas likewise separates the two lay- 
ers, compressing the lung. The closed pleural cavity shows 
a negative pressure, and when opened the positive pressure 
of the outside air instantly allows the lung to collapse. 
When the opening to the outside air, however, is closed, the 
air inside is slowly absorbed and the lung expands again. 
When from disease an opening from the lungs into the 
pleural cavity occurs, the lung is likewise collapsed more or 
less suddenly and a pneumothorax is formed, the pressure 
on the inside being the same as that of the outer air. The 
parietal or costal layer of the pleura is attached to the chest 
wall by connective tissue and when from an injury or punc- 
ture, as in artificial pneumothorax, air enters into the space 
between the chest wall and costal pleura, a deep emphysema 
is developed. 

When the cavity of the pleura requires tapping to evacu- 
ate fluid the sixth or seventh intercostal space midway be- 
tween the sternum and spine is usually selected. 

The right and left pleural cavities are separate and dis- 
tinct; and the parietal pleura, at the point of its reflection 
upon the upper part of the diaphragm, is called the inferior 
cul-de-sac of the pleura; hence, we can have diaphragmatic 
pleurisy. 

Lymphatics of the Pleurae 

The lymphatics of the pleura are abundant, both in the 
parietal and visceral layers, those of the latter connecting 
with the lymphatics of the lungs, and those of the former 
with the lymphatics of the thoracic wall. It is through this 



1 6 PULMONARY TUBERCULOSIS 

lymphatic system in conjunction with the respiratory move- 
ments that the pleuritic fluid is chiefly absorbed. 

The Lungs 

The lungs fit into the pleura-lined chest, the rounded apex 
projecting about one and one-half inches above the sternal 
end of the clavicle and the concave base fitting accurately 
upon the convex top of the diaphragm. The lower limit of 
the lungs can be represented by a line drawn around the 
chest from the junction of the sixth costal cartilage with 
the sternum to the spinous processes of the tenth dorsal 
vertebrae. The right lung (Fig. 2) is shorter and broader 
than the left and has three lobes and two fissures. The left 
lung (Fig. 3) has two lobes and one fissure. The lungs 
occupy four-fifths of the thoracic cavity, the remaining space 
being occupied by the heart and hilus of the lungs, formed 
by the bronchi, the pulmonary artery and vein, the lym- 
phatic vessels, nerves and glands. 

The normal weight of the lungs varies between 1100 and 
1200 grams (5 or 6 lbs.) in the male, and 900 to 1100 grams 
(4.1 to 5 lbs.) in the female. 

The substance of the lungs is of a spongy texture, con- 
sisting of a mass of minute cavities — the alveoli or air cells — 
which are encircled by a mesh of capillary vessels only sep- 
arated from the air by the exceedingly thin membrane of 
the alveoli and the whole structure is connected together by 
areolar fibrous tissue. By this mechanism the oxygen en- 
tering the lungs is absorbed by the blood and carbon di- 
oxide, nitrogen and watery vapor excreted. Elastic tissue 
enters largely into the composition of the lungs and upon 
this elastic tissue their contractility largely depends so that 
when the chest is opened the lungs collapse to about a third 
of their ordinary size. In emphysema of the lungs this 
elasticity is to a great extent lost and, in consequence, they 
are in a constant state of distension. 

The general shape of the lungs is triangular, or conical, 
and is conformed to the shape of the thoracic cavity. In 
front the anterior edges of the lungs do not come together 
in tranquil breathing, while in forced inspiration they meet 




Fig. 4. Longitudinal section through the right mammary line 

From Garre und Quincke, Lungenchirurgie 



ANATOMY AND PHYSIOLOGY 1 7 

over the base of the heart. The anterior edge of the right 
lung is nearly vertical, while that of the left is oval or 
oblique. 

Boundaries of the Lungs and Lobes 

Above, the lungs extend about one and one-half inches 
beyond the sternal end of the clavicle ; below, from the sixth 
costal cartilage of the sternum to the spinal processes of the 
tenth dorsal vertebrae. The following table will be useful 
in fixing in one's mind the boundaries of the lobes : 

Right Lung; Three Lobes 



Upper 
Lobe 


Anteriorly Laterally 
Apex to To Fourth Rib 
Fourth Rib 


Posteriorly 
Apex to Spine of 
Scapula 


Middle 
Lobe 


Anteriorly Laterally 
Fourth Rib to In- Fourth to 
ferior Angle of Sixth Rib 
Sixth Rib 


Posteriorly 
Nil. 


Lower 
Lobe 


Nil. Sixth to 

Eighth Rib 

Left Lung; Two Lobes 


Spine of Scapula 
to Tenth Rib 


Upper 
Lobe 


Apex to Sixth To Fourth Rib 
Rib 


Apex to Spine of 
Scapula 


Lower 
Lobe 


Nil. Fourth Rib to 
Base 


Spine of Scapula 
to Tenth Rib 



One can easily remember that in front on the right side 
we have the upper and middle lobe (Fig. 4), and on the left 
the upper lobe (Fig. 5), while behind we have an upper and 
lower lobe on each side. It is helpful to remember the 
boundaries of the lobes of the lungs, and particularly to 
bear in mind how large a part of the organ, posteriorly, 
consists of the lower lobe. It is of aid in determining the 
extent of a pneumonic consolidation; whether or not a tu- 
berculous process has invaded the lower lobe; and in mak- 
ing a diagnosis between solidification of the lower lobe and 
an efTusion. 

Lymphatics of the Lungs 

The lymphatics of the lungs, which are abundant, are 
superficial and deep and terminate at the root of the lungs 
in the bronchial glands, which lie along the lower portion 



l8 PULMONARY TUBERCULOSIS 

of the bronchi and trachea. These glands readily enlarge 
in various infectious diseases, particularly in tuberculosis 
in children and in primary tuberculosis in adults. Such en- 
larged glands can be detected by the X-ray and also some- 
times can be made out with more or less definiteness by 
percussion and auscultation. When much enlarged they 
give rise to cough and dyspncea (Fig. 6). (Fig. 7.) 

The Bronchi and Trachea 

The lungs are connected with the outer air by means of 
the bronchi and trachea. The latter starts opposite the 
lower border of the sixth cervical vertebra and ends be- 
tween the fourth and fifth thoracic vertebrae. It is four to 
four and one-half inches long, and bifurcated into the bron- 
chi just above the level of the junction of the manubrium 
sterni and gladiolus. The right bronchus follows more 
nearly than the left the course of the trachea. From the 
two main stems are given off lateral branches and these di- 
vide and subdivide until at last they terminate in the lobules 
and these again in the intercellular passages and air cells. 

The bronchi are accompanied by branches of the pul- 
monary artery, the lymphatics and nerves. The arch of 
the aorta is in close relation with the left bronchus and in 
aortic aneurysm we may have partial or complete obstruc- 
tion of the bronchus, and as a result the development of 
acute bronchiectasis. 

Landmarks of the Lungs (Holden) 

1. "The apex of each lung rises into the neck behind the 
sternal end of the clavicle and the sternomastoid muscle 
about one and one-half inches." 

2. "There is little or no lung behind the first bone of the 
sternum." 

3. "From the level of the second costal cartilage to the 
line of the fourth the margins of the lungs run parallel, or 
nearly so, close behind the middle of the sternum." 

4. "Below the level of the fourth costal cartilage the mar- 
gins of the lungs diverge, that of the right corresponds with 




Fig. 5. Longitudinal section through the left mammary line 
From Garre und Quincke, Lungenchirurgie 



ANATOMY AND PHYSIOLOGY 1 9 

the direction of the cartilage of the sixth rib, while that of 
the left being notched for the heart, runs behind the carti- 
lage of the fourth rib. A line drawn perpendicularly from 
the nipple would find the lung margin about the lowest part 
of the sixth rib." 

5. "In deep inspiration the lung margins descend about 
one and one-half inches." 

The Shape of the Chest and Its Modification by Disease 

In the normal chest the antero-posterior diameter is about 
one-fourth less than the transverse diameter. The hori- 
zontal section of the chest shows the general form of an 
ellipse. The adult female chest is generally more barrel- 
shaped than the male chest. As abnormal modifications, 
we have : 

(a) The emphysematous chest which is more or less 
barrel-shaped. 

(b) The flat chest, the so-called "phthisical chest," al- 
though a flat chest does not necessarily indicate a tendency 
to tuberculosis. 

(c) The "pigeon-breasted," also called the "keel chest" 
which is characterized by its triangular shape : the sternum 
is pushed forward, increasing the antero-posterior diameter. 
This deformity is caused by a long existing impediment to 
free inspiration, such as enlarged tonsils, adenoids, or by 
chronic bronchitis or whooping cough. 

(d) The rachitic chest where there is a lateral compres- 
sion of the chest walls and a relative increase in the antero- 
posterior diameter. 

(e) The funnel, gutter or cobbler's chest, characterized 
by a depression of the lower part of the sternum. This 
formation may be the result of rickets, or it may be con- 
genital or acquired, as in the case of the cobbler. 

(f) The "Alar-chest," in which the angles of the scapulae 
project which gives them a wing-like appearance. Such a 
chest is generally of small capacity and is supposed to sug- 
gest a predisposition to tuberculosis. 

We have also unilateral changes in the chest: one side 



20 PULMONARY TUBERCULOSIS 

may be increased in size over the other, as from pleural 
effusions, pneumothorax, or compensatory hypertrophy; or 
one side may be retracted, as from tuberculous contractions, 
the result of long compression of the lung by pleural effu- 
sion, or of an empyema. 

Again, we may have local changes in the shape of the 
chest, such as bulging in the lower anterior or lateral region, 
as in the case of empyema where the pus tends to be evacu- 
ated; or a contraction above and below the clavicle, which 
is frequently observed in tuberculosis. Other causes are 
atelectasis, bronchiectasis, and pleural adhesions. 

Physiology of Respiration 

Respiration consists of two separate acts, inspiration, 
which is essentially active, and expiration, which is almost 
entirely passive. The muscles engaged in ordinary inspira- 
tion are the intercostals, the diaphragm, the levatores cos- 
torum, scaleni and serati postici. The movements of ex- 
piration are chiefly due to the elasticity of the lungs and the 
passive return of the diaphragm and chest walls. In ordi- 
nary quiet breathing there is comparatively little rib move- 
ment, especially in the upper half of the thorax, inspiration 
being almost entirely abdominal. This is less so with 
women. In extraordinary inspiration many other muscles 
come into play, — indeed, all the muscles about the chest, 
which by fixing their point of attachment can aid in elevat- 
ing the ribs and expanding the chest, such as the pectorals, 
latissimus dorsi, quadrati lumborum, sterno-mastoid, erector 
spinse and trapezius. In a severe attack of asthma, for ex- 
ample, many of these muscles can be seen at work in a fran- 
tic attempt to get more air into the lungs. Any impediment 
to the free movements of the chest or action of the muscles 
of respiration obviously interfere with free adequate respira- 
tion. Such impediments may be pathological or mechanical. 
Of the former we may have diseases of the lungs, pleural 
effusions, aneurysm of the aorta, curvature changes in the 
thoracic walls, ascites, peritonitis, abdominal tumors, etc. 
Of the latter — mechanical — are posture, flatulent distension 
of the stomach, constriction, as from tight corsets. 




Fig. 6. The relationship of the bronchial glands to the anterior 
thoracic walls 

From Stoll — "American Journal of Diseases of Children"— 1912 — vol. 4. 333~359> 



ANATOMY AND PHYSIOLOGY 21 

The general movement of the chest is also greatly dimin- 
ished in emphysema, in certain cases of asthma, and from 
injuries to or diseases of the spinal cord which paralyze the 
muscles of respiration. The movements of one side of the 
chest may also be diminished, as in pleural effusion, pneumo- 
thorax, pneumonia and tuberculosis. 

Increased expansion occurs during violent exercise; in 
the early stages of febrile diseases; from various emotional 
disturbances, and sometimes in dyspnoea. When in the 
case of an unilateral tuberculosis increased expansion of the 
other lung occurs, it is a favorable prognostic omen. There 
is a retraction or general drawing in of the intercostal spaces 
when there is any obstruction to the entrance of air, as in 
croup, the pressure of an enlarged thyroid gland, an aneu- 
rysm, or a tumor pressing on the trachea or bronchi. This 
also sometimes happens in bronchial asthma. 

The relation of the act of inspiration to that of expiration 
is as 5 to 6; but the relative duration of the sounds, however, 
are as 3 to 1, while the expiratory sound is often quite 
inaudible. 

The circumference of the normal chest averages 34 inches, 
or 87 cm., and the expansion on forced inspiration from one 
and one-half to five inches, or 4 to 13 cm. Much depends 
upon practice in deep breathing. 

Vital Capacity of the Lungs 

The vital capacity of the lungs, or the amount of air ex- 
haled on a forced expiration, after a forced inspiration, is 
about 230 or 240 cubic inches, or 3600 ex. in men and 150 
cubic inches, or 2500 ex. in women. In one thousand obser- 
vations which I made upon males from sixteen to forty years 
of age, I found the average to be 240 cubic inches. The 
vital capacity is measured either by the water or dry spiro- 
meter. The vital capacity is generally diminished in all 
diseases of the respiratory organs, and hence this measure- 
ment is of some value in judging of improvement in a case 
of tuberculosis, for example. 

The "tidal air," the amount of air inhaled and exhaled in 
quiet breathing, is about 500 ex. or 30 cubic inches. The 



22 



PULMONARY TUBERCULOSIS 



"complemental air," the additional amount one can take in 
by forced inspiration, is from 1500 to 2000 c.c. or 90 to 120 
cubic inches; and the "supplemental air," the additional 
amount one can exhale in excess of the normal tide, by 
forced expiration, is from 1200 to 1500 c.c. or 72 to 90 cubic 
inches. The "residual air," what is left in the lungs at the 
end of forced expiration, is estimated at from 1200 to 1500 
c.c. or 72 to 90 cubic inches. 

The following measurements which the writer made and 
collected will serve as fairly accurate standards of chest 
measurements and lung capacity. The "muscular" circum- 
ference of the chest was taken at the level of the nipples 
and the "respiratory" circumference two inches below: 



Measurements of the Chest and Lung Capacity 

TABLE I 

Chest Measurements 

girth of chest, muscular Repose Inflated Difference 

Men inches inches inches 

Average of Dr. E. O. Otis, one thousand 
measurements, between sixteen and forty 

years of age 34-0 36.1 2.1 

Average of Dr. Hitchcock, of Amherst Col- 
lege. Eight thousand measurements 34.6 36.5 1.9 

Average of E. Hitchcock, Jr., of Cornell Col- 
lege. Fifteen thousand measurements... 34.5 36.3 1.8 
Women 
Mt. Holyoke and Wellesley students. Meas- 
urements of Miss Wood and Dr. Mary 

Colton - 29.5 31.5 2.0 

respiratory chest 

Men 

Average of Dr. E. O. Otis. One thousand 

measurements 31.1 33.1 2 -° 

Women 
Fifty per cent, of fifteen hundred Wellesley 

students. Miss Wood 24.6 27.2 2.6 

Measurements of the Chest and Lung Capacity 
Continued 
depth of chest Repose Inflated Difference 

Men inches inches inches 

Average of Dr. E. O. Otis. One thousand 
measurements in repose and one hundred 

and twelve measurements inflated 7.3 8.2 0.9 

Women 
Fifty per cent, of fifteen hundred students 
at Wellesley. Miss Wood 6.9 




Fig. 7. The relationship of the bronchial glands to the posterior 
thoracic walls 
From Stoll — "American Journal of Diseases of Children" — 1912 — vol. 4. 333-359 



ANATOMY AND PHYSIOLOGY 23 

BREADTH OF CHEST 

Men 
Average of Dr. E. O. Otis. One hundred 
and fifty measurements 9.6 10.8 1.2 

TABLE II 

Capacity of Lungs 

Cubic 
Men Inches 

Average of Dr. E. O. Otis. One thousand measurements 240.6 

Hitchcock. Eight thousand measurements 230.0 

Hitchcock, Jr. Fifteen thousand measurements 236.6 

Women 
Mt. Holyoke and Wellesley students. Measurements of Miss Wood 

and Dr. Mary Colton 145-8 

Fifty per cent, of fifteen hundred Wellesley students. Miss Wood... 150.3 

TABLE III 
Comparison of the "Vital" or Lung Capacity and the Amount of Air 
Expelled after an Ordinary Quiet Inspiration. Average of Dr. E. O. 
Otis. One Hundred and Fifty Measurements 

Cubic 

Inches 

Vital capacity, or the amount of air exhaled after a full inspiration.. 230.5 

Amount of air exhaled after an ordinary quiet inspiration 129.3 

Difference, or "complemental" or "reserve" air , 101.2 

Average Lung Capacity for Height 

Average for each inch 
Height. Lung Capacity or Centimeter 

in Height. 

66 to 67 inches, incl. 231.62 c. in. 34+c in. 

167.7 to 170.3 cms. 3.797 c. cms. 22.4 c. cms. 

67 to 68 inches, incl. 237.10 c. in. 3.46 c. in. 

170.3 to 172.8 cms. 3,903 c. cms. 22.7 c. cms. 

68 to 69 inches, incl. 244.44 c. in. 3.5 c. in. 

172.8 to 175.4 cms. 4,007 c. cms. 23.06 c. cms. 

69 to 70 inches, incl. 259.34 c. in. 3.64 c. in. 

175.4 to 177.9 cms. 4,250 c. cms. 24.06 c. cms. 

70 to 71 inches, incl. 261.38 c. in. 3.64 c. in. 

177.9 to 180.5 cms. 4.284 c. cms. 23.9 c. cms. 

71 to J2 inches, incl. 261.34 c. in. 3.5 c. in. 

180.5 to 183 cms. 4,284 c. cms. 23.03 c. cms. 

General Average \ 3-52 cubic inches. 

( 23.19 cubic cms. 

As has been said, the expiratory act, although essentially 
passive as regards the muscles of respiration, takes place by 
a shrinkage of the lung tissue by means of its elasticity. 
When this elasticity is impaired by degenerative changes 
or disease, expiration is incomplete or difficult. Normal 
respiration occurs at the rate of about 16 times per minute. 
We may say anything between twelve and twenty is normal. 
The ratio of the respiration to the pulse rate is about one 
to four or five. 



24 PULMONARY TUBERCULOSIS 

Abnormalities of Respiration 

(a) Dyspnoea — difficult, rapid, labored respiration — oc- 
curs in a variety of conditions, such as heart disease, pneu- 
monia, extensive pleural effusion, asthma, tuberculosis, 
anaemia, and acute infections. We have both expiratory 
and inspiratory dyspnoea. When both exist, which is com- 
monly the case, it is called mixed dyspnoea. Functional 
dyspnoea occurs as a result of violent exercise or emotional 
disturbances. 

(b) Orthopnoea: excessive dyspnoea, when the patient is 
obliged to sit up and make great effort in order to breathe 
more easily. 

(c) Obstructive dyspnoea, from some hindrance to free 
entrance of the air into the lungs, caused by various ob- 
structions in the pharynx, larynx, trachea or bronchi, such 
as enlarged tonsils, peritonsillar abscess, oedema glottis, for- 
eign bodies in the upper respiratory tract, stenosis of the 
larynx or trachea, aneurysm, tumors, etc. 

(d) Apnoea: a temporary cessation of breathing, illus- 
trated in so-called "Cheyne-Stokes" respiration, which is 
characterized by a waning and waxing of the respiration. 
Beginning with a number of superficial respirations, they 
gradually deepen until full respiration or even dyspnoea is 
reached; then the respirations decline in force and length 
until a state of apnoea occurs which may last so long that 
one may believe that the patient is dead. 

(e) Asphyxia: a sudden arrest of respiration from out- 
ward violence, as in choking, or in apparent drowning. In 
many instances of apparent death from asphyxia, resuscita- 
tion may be effected by means of artificial respiration at 
once applied and continued for a long time. 

Other abnormalities of respiration are indicated by the 
names given them, as stertorous, stridulous, asthmatic, shal- 
low, jerky, sighing, catchy, restricted. 

A study of the respiration, both in health and disease, 
is of much value and conveys much useful information. 
Breathing exercises are an important preventive measure 
as well as a valuable aid in some of the abnormal conditions 



ANATOMY AND PHYSIOLOGY 25 

of the lungs. Proper full respiration is, in modern life, 
more or less of an acquired habit, and it is of importance 
that the physician himself should first learn to breathe cor- 
rectly and then he will be able to teach his patients to do 
the same. There are a few easily acquired breathing exer- 
cises, both simple and efficient, which will develop the chest 
and increase the lung capacity, and which will be of value 
in preventing disease, as well as helpful in the treatment of 
various diseases. For an exhaustive study of this subject, 
one is referred to the treatise upon "Respiratory Exercises 
in the Treatment of Disease" by Harry Campbell, M. D. 
N. Y. Wm. Wood & Co. 



CHAPTER II 
THE HISTORY OF TUBERCULOSIS 

"Other men labored, and ye are entered into their labors." — John, iv, 38. 

The world-wide prevalence of tuberculosis, its predom- 
inant influence in medicine, and its antiquity warrant some 
brief mention of its history, that we may learn through what 
labor and sacrifice our present knowledge of the disease has 
come down to us. When and how did tuberculosis have its 
origin? No one knows; all we know is that "phthisis" or 
"consumption," as it was called, has existed almost as long 
as recorded events. As some one has expressed it, "it has 
always existed." 

That celebrated physician of antiquity Hippocrates, who 
was born about the time of Socrates (460-377 B. C), the 
supposed period of the Jewish return from their exile at 
Babylon, gives the first clear clinical description of the dis- 
ease. He considered it to consist of a suppuration of the 
lungs, which might be of an acute or chronic nature; that 
it resulted from mucus, blood or other morbid products in 
the lungs or pleural cavity, which failing to be absorbed 
was changed into purulent matter. He thus describes the 
course of "phthisis" : "With many persons," he says, "it 
commenced during the winter, and of these some were con- 
fined to bed, and others bore up on foot; the most of these 
died early in the spring who were confined to bed; of the 
others the cough left not a single person, ... in the greater 
number of cases the disease was long protracted." In his 
aphorisms he says : "Phthisis most commonly occurs be- 
tween the ages of 18 and 35." 

"In persons who cough frothy blood, the discharge of it 
comes from the lungs." 

"Diarrhoea attacking a person afflicted with phthisis is a 
mortal symptom." {Adams' translation.) 

26 



THE HISTORY OF TUBERCULOSIS 2J 

Hippocrates recommended tar as a remedy, suggestive 
of the modern creosote treatment. 

Isocrates, a contemporary of Hippocrates, considered pul- 
monary phthisis to be a contagious disease, — a keen ob- 
server. 

In the first century of the Christian era (50 A. D.) Are- 
taeus Cappadox, a celebrated Greek physician, wrote very 
intelligently of the disease and was the first to clearly de- 
scribe pulmonary tuberculosis, or phthisis, as it was then 
called, as a definite pathological process. He considered it 
to be caused by abscess of the lungs, chronic bronchitis or 
pulmonary hemorrhage from which pus might be formed 
in the lungs. For treatment he recommended sea voyages 
and the use of milk and eggs. Celsus, a Roman contem- 
porary of Aretseus, held that there were three forms of con- 
sumption: (a) an atrophy of the lungs; (b) cachexia; (c) 
ulceration of the lungs. He advised the use of mutton suet 
boiled in flour. 

Galen (130 A. D.), the most eminent physician after Hip- 
pocrates, held views as to the pathology of the disease simi- 
lar to those of his great predecessor. He considered it to 
be an ulceration or suppuration of the lungs ; the destroyed 
portions being discharged in the expectoration. This con- 
dition he compared with ulceration of other organs, as of 
the stomach, bladder, etc. In his opinion the disease was 
due to irritation or injury of the lung tissue followed by 
hemorrhage, although he recognized that ulceration of the 
lung might occur without hemorrhage, caused by corrupt 
secretions. When the disease occurred in this way, he con- 
sidered it incurable. He also mentions its infectious nature. 
He recommended the same treatment as had been found suc- 
cessful in treating ulcers in other organs, namely, such meas- 
ures as would dry up secretions ; hence, he used to send his 
consumptive patients to dry, elevated resorts. He also 
advised a milk diet. 

After Galen, a long period elapsed before any advance was 
made in the knowledge of phthisis. Indeed, it was not until 
the middle of the seventeenth century, when practical an- 
atomy began to be studied — the "Anatomical Period" — that 



25 PULMONARY TUBERCULOSIS 

there was any notable advance in the knowledge of the 
disease. 

Sylvius (1614-1672) was the first to accurately describe 
tubercles of the lungs. In his "Tractus de Phthise" he at- 
tributes the ulceration of the lungs to the suppuration of 
tubercles which in softening finally produced cavities. He 
believed that there were two varieties of pulmonary 
phthisis : the one due to purulent infiltration of the lungs 
(the Hippocratic and Galenic theory) caused by hemoptysis, 
or empyema, and characterized by ulceration, suppuration 
and destruction of lung substance ; and that the other variety 
was the result of a scrofulous constitution due to enlarged 
lymph glands or nodes in the lungs which suppurated, soft- 
ened and were converted into tubercles. 

Richard Morton (1689), an English physician, was the 
most important investigator after Sylvius, and in his cele- 
brated work on "Phthisiology" he emphasizes the tubercle 
as the true cause of the disease and that phthisis was always 
dependent upon it. Like Sylvius he also noted the rela- 
tion between phthisis and scrofula. Morton was the first 
who maintained that the tubercle was a necessary antecedent 
to ulceration. Morton recognized the great prevalence of 
consumption, and in the following quotation he seems to 
have truly divined what we all now believe, that almost every 
adult has some tuberculous infection. He says : "Yes, 
when I consider with myself how often in one year there is 
cause enough ministered for producing these swellings, even 
to those that are wont to observe the strictest rules of liv- 
ing, I cannot sufficiently admire that any one, at least after 
he comes to the flower of his youth, can dye without a 
touch of consumption." 

As time went on, mam- other eminent investigators, as 
Sydenham (1 624-1 669), Boorhaave (1668-1738), Swieten 
( 1 700-1 732), Morgagni (1 682-1 771), Auenbrugger (1722- 
1809) (the discoverer of percussion) wrote upon phthisis 
but giving essentially the same views as their predecessors. 

The next most important advance in the pathology of 
phthisis was made by Matthew Baillie in 1793, who, in a 
small treatise entitled "The Morbid Anatomy of the Most 



THE HISTORY OF TUBERCULOSIS 20, 

Important Parts of the Human Body," describes as the most 
frequent lesion in the diseased lung the presence of small 
nodes, at first about the size of the head of a pin, which 
later coalesce and increase in size. These nodes breaking 
down and suppurating he regarded as the cause of consump- 
tion. Baillie appeared to make a distinction between scrof- 
ulous glands and the nodes or tubercles, although he held 
that they both possessed the common property of being 
changed into caseous matter. 

Bayle (1774-1816) may be considered the founder of the 
modern pathology of pulmonary tuberculosis. He started 
with the miliary tubercle and described its development from 
the solid condition to the stage of caseation and softening. 
Since tubercles occurred in other organs of the body, he 
concluded that phthisis was not a disease confined to the 
lungs alone. He considered it a general disease of a spe- 
cific nature, and not a local one, caused by inflammation of 
the glands or lymphatic system. He believed that hemop- 
tysis was a result and not a cause of tuberculosis. He made 
six types or forms of phthisis, namely: 

(a) Tuberculous phthisis. 

(b) Granular phthisis. 

(c) Phthisis with melanosis. 

(d) Ulcerative phthisis. 

(e) Calculous phthisis. 

(f) Cancerous phthisis. 

Laennec (1781), the inventor of the stethoscope and the 
discoverer of mediate auscultation, maintained that there 
was but one species of phthisis, namely, the tuberculous, 
and he considered phthisis and tuberculosis of the lungs as 
identical, both having their origin in the miliary tubercle. 
This was called the "Unity Theory." Louis (1827), the 
great French physician and successor of Laennec, also 
agreed with his predecessor and adopted his views. 

With Laennec and his school the period of open-eyed 
observation closed and that of histological investigation 
followed. 

Virchow (1850), an eminent German pathologist and the 



30 PULMONARY TUBERCULOSIS 

founder of the so-called "cellular pathology," was the father 
of the "dualistic theory," which was that there were two 
kinds of phthisis : — 

(a) Tuberculous phthisis. 

(b) Caseous pneumonia. 

Virchow also held that caseation was a general pathological 
change met with in many morbid products and not peculiar 
to tubercle. 

Niemeyer (1866), a distinguished follower of Virchow, 
strenuously sustained his master's theory, and thought that 
the worst fate that could befall a consumptive was to be- 
come tuberculous. For many years Niemeyer's text book 
upon general medicine was the standard one in the medical 
schools, and so the dualistic theory was generally taught and 
accepted. 

We come now, finally, to the period of experimental in- 
vestigation. 

Klencke (1843) produced tuberculosis in rabbits by in- 
jecting into their jugular veins tubercle cells taken from 
miliary tubercles and from tubercles in the stage of gray 
infiltration. It is doubtful if he himself fully appreciated 
the importance of his discovery. However it may be, his 
work was forgotten and had no influence upon the existing 
theory of tuberculosis. 

Villemin (1865), a French army surgeon, repeated on a 
far more extensive scale the experiments of Klencke. He 
inoculated rabbits with matter and sputum from tuberculous 
individuals and also from the tuberculous tissue of a cow. 
In every case he produced tubercles in the lungs. When 
he injected animals with pus, however, no tuberculosis re- 
sulted. Villemin's paper presenting his experiments and 
their results, published in 1865, may be classed with Koch's 
later contribution upon the discovery of the tubercle bacil- 
lus, as great epochal contributions to scientific medicine. 
Villemin, however, did not escape the lot which befalls most 
discoverers of new things in medicine. His conclusions 
were so novel and so at variance with the accepted ideas of 
the time that they did not receive universal acceptance. 



THE HISTORY OF TUBERCULOSIS 3 1 

Furthermore, some authorities thought that his experiments 
were faulty and hence his conclusions were to be doubted. 

Conheim, however, in 1877 repeated and amplified Vil- 
lemin's experiments. He injected tuberculous matter into 
the anterior chamber of the eye of a rabbit and thus by ocu- 
lar proof demonstrated the fact of the inoculability of tuber- 
culosis, for he saw the gradual development of the specific 
tubercle. 

Other investigators corroborated these experiments of 
Villemin and Conheim. Thus, finally, that which had been 
suspected or believed to be true — that tuberculosis was 
communicable — for so many years, nay, centuries, became 
a demonstrated fact. Isocrates, six centuries before Christ, 
believed tuberculosis to be contagious, as we have seen, and 
in 1638 Lazarus Riverius, in his "Practice of Physik," one 
of the chief works of medicine of his time, thus wrote: 
"Moreover there are causes of pulmonary phthisis, as con- 
tagion, which is chiefest, for this disease is so infectious that 
we may observe women to be infected by their husbands and 
men by their wives and all their children to die of the same, 
not only by heredity but from the company of him who was 
first affected." 

In 1754 Florence enacted sanitary laws regarding tuber- 
culosis and in 1782 Naples did likewise, isolating consump- 
tives and destroying their belongings. In 1760 a special 
hospital was erected in Olibuzza for the isolation of con- 
sumptives to which they were removed from other hospitals. 
In Spain and Portugal similar precautions were taken. 
Physicians in Italy who did not report their cases of con- 
sumption were fined 300 ducats (between $600 and $700) 
for the first offense and for the second were exiled for ten 
years. Rather a more serious penalty for failing to report 
cases of the disease than that existing today! Physicians 
who refused to send their consumptive patients to the spe- 
cial hospital for such cases, or removed them without the 
knowledge of the officers of health, were given three 
months' imprisonment, if of low birth, or fined 300 ducats, 
if of noble birth. 

Thus, after long years of observation, patient investiga- 



32 PULMONARY TUBERCULOSIS 

tion and experiment, it was definitely established that con- 
sumption always took its origin in the tubercle and that it 
was communicable or infectious. The next step was to 
determine how the infection took place, what caused the 
tubercle? Was it a specific micro-organism which entered 
the body from the outside? Pasteur's remarkable re- 
searches upon the bacterial origin of diseases and those of 
Tyndall's upon "Floating Matter of the Air in Relation to 
Putrefaction and Infection" suggested this. So the inves- 
tigations and discoveries in one department of science all 
unconsciously aid in the solution of problems in another 
scientific domain. 

Robert Koch (frontispiece), a German physician in a 
country town, conceived the idea that it was a specific "con- 
tagium vivum" which entered the body and set up the mech- 
anism of the tubercle formation, and he set about to see if 
he could prove it. At about this time the new science of 
bacteriology and the method of differential staining was 
beginning to be developed, and the compound microscope 
had been improved and perfected and the Abbe condenser 
added. With this idea in mind of a specific micro-organism 
as the cause of tuberculosis, and with the new tools of bac- 
teriology, staining, and the improved microscope, Koch be- 
gan his investigations, and after long, patient labor and 
many failures, he succeeded in demonstrating in the tuber- 
cles of recently killed animals the rod-like microscopic struc- 
ture which we know now as the tubercle bacillus. He in- 
variably found these micro-organisms in all tuberculous tis- 
sues, in the lungs, scrofulous glands, tuberculosis of the 
bones and joints; in lupus in the sputum of consumptives 
and in tuberculous cattle; in brief, in all diseases which from 
their nature and structure could be considered as tuber- 
culous. 

The next point to be determined was whether this tuber- 
cle bacillus was the sole and invariable cause of tuberculosis. 
Was this constantly recurring bacillus an actual, independent 
organism, or was it the product of disintegrating tissue? 
To prove this point Koch saw that he must obtain a pure 
culture of the bacillus and inoculate animals with it and see 




f. <°- ^uaAj&uu^ 



From Steel Engraving in possession of the National Tuberculosis 
Association; reproduced in Journal of "The Outdoor Life" 



THE HISTORY OF TUBERCULOSIS 33 

if tuberculosis ensued. After infinite plans and patience 
Koch succeeded in cultivating a pure crop of the tubercle 
bacilli upon a medium of blood serum. Now came the cru- 
cial step in the investigation : would these pure cultures of 
the tubercle bacillus produce tuberculosis in well animals? 
One can well imagine the intense expectancy of Koch as he 
proceeded to this last and deciding step in his experiment. 
He inoculated with his pure culture 217 animals, — 94 guinea- 
pigs, 70 rabbits, 9 cats and 44 mice, and then with intense 
interest he awaited the result. His state of mind must have 
been similar to that of all great discoverers. Franklin with 
his kite and key in the thunder storm ; Morse with his tele- 
graph; Bell with the telephone; Marconi with wireless teleg- 
raphy. Not a single one of the animals inoculated escaped 
tuberculosis. At the same time Koch injected all kinds of 
diseased tissues into guinea-pigs and rabbits and the result 
was always negative to tuberculosis. 

Thus finally the truth regarding the true aetiology of 
tuberculosis was revealed, after centuries of ignorance of 
its cause. By Koch's supreme achievement tuberculosis 
is known to the world as an infectious or communicable dis- 
ease, the sole cause of which is the tubercle bacillus. Little 
by little, as we have seen in the foregoing pages, our knowl- 
edge of the disease increased and grow more definite through 
the study of the many investigators through the years, until 
the final consummation came. 

So does "science move but slowly, 
Slowly creeping on from point to point." 

Koch issued an account of his discovery and its demonstra- 
tion in 1882. As always with regard to any great discovery, 
some doubted his results, but no one was able to disprove 
them. As Osier has well said: "The enemy is known, its 
life history is known, the mode of entrance into the system 
is known, and this has been followed by the fourth stage in 
the history of the disease, the period of prevention." 

One can hardly close this account of the history of tuber- 
culosis and those who were eminent in advancing our knowl- 
edge of it without reference to Dr. E. L. Trudeau, the pion- 



34 PULMONARY TUBERCULOSIS 

eer in this country of the open-air and sanatorium treatment 
of the disease, and in the establishment of a laboratory for 
its study. 

Going to the Adirondacks in 1873, a sufferer from pulmo- 
nary tuberculosis, and being benefited by the change of air, he 
conceived the idea of founding a sanatorium in this region 
for the poor and those of limited means, and in 1885 the first 
small cottage was erected for this purpose, which was the 
first institution of its kind in this country. From this hum- 
ble beginning the "Adirondack Cottage Sanatorium" has 
grown under the fostering care of Dr. Trudeau — until it has 
become a "picturesque little village" with all the equipment 
of the most modern institutions for the treatment and study 
of tuberculosis. Dr. Trudeau was also a constant student 
and investigator of the disease, and founded the "Saranac 
Laboratory," the first one devoted to the study of this dis- 
ease in this country, which has now become one of the lead- 
ing institutions for tuberculosis investigations. 

For many years Dr. Trudeau worked incessantly in the 
development of the sanatorium, and in the study of tuber- 
culosis in his laboratory, particularly in the investigation of 
infection and immunity. He never fully recovered from his 
disease; indeed he would never give himself time for effec- 
tive treatment, and died at Saranac in November, 1915, at 
the age of sixty-six years, honored and esteemed by all tuber- 
culosis workers for his contributions in the treatment and 
study of the disease. 



CHAPTER III 
PATHOLOGY AND BACTERIOLOGY 

"Diseases are often to be traced by visible changes of structure in the in- 
ternal parts of the body. . . . They throw light upon what is past ; they afford 
some guidance for the time to come." 

Thomas Watson. 

The tubercle bacillus is an infinitesimally small, slender 
rod, in length from one-quarter to one-half the diameter of 
a red blood corpuscle. It is frequently more or less curved, 
and sometimes has an irregular knobbed appearance. When 
once well recognized in its red color, its characteristic ap- 
pearance can never be forgotten or mistaken. It may occur 
in chains or in small clumps. It is a parasite and does not 
multiply outside of the body, except when grown upon a 
favorable medium. It belongs to the class of acid fast or 
acid proof bacilli and its envelope is penetrated by stains with 
difficulty. Acids do not remove the stain. It is a long lived, 
tough parasite, and under favorable conditions may retain 
its vitality for several months. Hidden away in dark, damp 
corners, it lies in wait for its victim, or mounted upon parti- 
cles of dust, it roams about ready to be inhaled or ingested 
by any one living in the dust-laden atmosphere. Floating 
on dust in the air, the bacillus may retain its infectivity for 
eight or ten days. 

It is destroyed by sunlight in a few hours, and by diffuse 
daylight in twenty-four hours. Various germicides kill it; 
for example, a five per cent, solution of carbolic acid added 
to an equal volume of sputum will kill the bacilli in .twenty- 
four hours. So will a two per cent, lysol solution, or a fif- 
teen to twenty per cent, solution of formalin. An equal 
volume of the disinfecting solution must be used and 
thoroughly incorporated with the sputum. It must be borne 

35 



36 PULMONARY TUBERCULOSIS 

in mind that when the tubercle bacilli are enclosed in mucus 
it requires a longer time to destroy them. Heat at a tem- 
perature of 150 to 160 F. also kills the bacilli when moist 
in from ten to fifteen minutes. When dry, it requires a 
higher temperature for a longer time. In milk, a tempera- 
ture of 140 to 167 F. continued for one hour is also effec- 
tive. Pasteurized milk (heated to from 155 to 158 F. for 
twenty to thirty minutes) can be considered safe. Cold to 
any degree has no destructive influence upon the bacillus. 
It will retain its vitality for a considerable time in decom- 
posing animal tissues, and it has been found in the soil of 
sewage fields. The gastric juice, although it impedes its 
development, from its acidity, does not destroy it. It has 
been estimated from carefully obtained data that a consump- 
tive may expectorate 500,000,000 to 3,000,000,000 tubercle 
bacilli in twenty-four hours. It is to be remembered that 
the dry bacilli retain their vitality for a long time, and hence 
the danger in a room where there is an unclean consumptive 
who allows his sputum to become dry and coughs in the air. 

Besides the human tubercle bacillus there is that of the 
bovine type which differs from the former in action and 
slightly in form. It is shorter, straighter, and thicker, and 
is more virulent for rabbits. Whether these two forms are 
distinct types or variations of a single type is a question still 
under discussion although, so far as investigation has gone, 
each type is distinct and stable. Both produce tuberculosis 
in man and animals, although the human tubercle bacillus 
less readily infects cattle than that of the bovine type. 
There is also a third type, the Avian, but this is not found 
in the human subject. 

The tuberculosis in children under five years of age in the 
form of tuberculous glands and abdominal tuberculosis has 
been found, in a certain number of cases, to be due to the 
bovine tubercle bacilli ingested in milk. From the investi- 
gations of Park and others the conclusion has been reached 
that from six and one-half per cent, to ten per cent, of 
deaths of young children from tuberculosis are from bovine 
source through infected milk. The obvious lesson is to 



PATHOLOGY AND BACTERIOLOGY $7 

secure milk from cows proved to be non-tuberculous or to 
pasteurize it. 

Staining the Tubercle Bacillus 

The simplest and quickest method of staining the tuber- 
cle bacillus, and the one ordinarily employed, is that of the 
Ziehl-Nielsen, and the technique is as follows: The morn- 
ing sputum is to be obtained if possible, and from it one of 
the grayish particles having the most consistency, and as be- 
ing the most likely to contain the bacilli, is selected and thin- 
ly and evenly spread over a cover glass or slide. This is dried 
by passing the glass rapidly three times through or over 
the flame of a Bunsen burner or alcohol lamp; thus the mate- 
rial is fixed. Next, this is stained with the carbol-fuchsine 
solution which is composed of saturated alcohol solution of 
fuchsine n c.c, and solution of carbolic acid (five per cent.) 
ioo c.c. Sufficient stain is used to entirely cover the film. 
This is then held over the flame for from thirty seconds to 
one or two minutes until steam arises, not allowing it to 
become dry. Wash in water and decolorize with the acid 
solution, which is composed of either nitric, hydrochloric 
or sulphuric acid in the proportion of five parts of concen- 
trated nitric acid to 95 parts of alcohol (80 per cent.), a three 
to five per cent, of hydrochloric acid in 80 or 90 per cent, of 
alcohol, or a twenty per cent, of sulphuric acid. The prep- 
aration is alternately put in the decolorizing fluid and washed 
until the red color disappears. After the final washing it 
is counter-stained with Loffler's methyline blue solution, al- 
lowing the solution to remain on the glass for from thirty 
seconds to one minute. This is then washed off with water, 
the glass dried, mounted, and examined with the oil-immer- 
sion lens. 

It is evident that a specimen of sputum may contain tuber- 
cle bacilli and yet the particular particle examined may give 
a negative result; and this is all the more likely to happen 
when there are but few bacilli in the whole specimen. In 
order to obviate so far as may be this possibility, two 
methods have been employed which have proved of much 



38 PULMONARY TUBERCULOSIS 

value, the object being to soften and concentrate the sputum 
and destroy other bacteria. These two methods are called 
(a) the antiformin and (b) the Ellerman and Erlandsen 
methods. 

The Antiformin Method 

Antiformin, which contains sodium hydroxide and sodium 
hypochlorite, is mixed with the specimen of sputum in the 
proportion of one part of the fluid to five parts of the spu- 
tum. This is allowed to stand for three or four hours, long 
enough for the sputum to soften; it is then diluted with 
water or alcohol and centrifugalized; the sediment is col- 
lected and again centrifugalized once or twice more, when 
the final sediment is stained and examined in the usual way. 

The Ellerman and Erlandsen Method. 

For the technique of this method I am indebted to Dr. 
H. M. King of the Loomis Sanatorium where it is in use. 

The entire expectoration of three days is collected in a 
clean wide mouth bottle. To this is added an equal volume 
of 0.6% sodium carbonate solution. After shaking, the mix- 
ture is placed in an incubator and allowed to digest at a 
temperature of 37 C. for twenty-four hours. The time of 
digestion should be increased with thick purulent specimens. 
The mixture is removed from the incubator, and should con- 
sist of two layers; the upper cloudy fluid, the lower a vary- 
ing amount of homogeneous sediment. The entire fluid 
portion is poured off (into 5% lysol or similar solution), and 
to the remaining sediment is added four or five volumes of 
0.25% sodium hydrate solution. The mixture is next trans- 
ferred to a suitable vessel and boiled for one or two minutes. 
Large test tubes (eight by one inch) or small beakers are 
found convenient. After cooling, the mixture is transferred 
to 50 ex. centrifuge tubes and centrifugated for ten or fifteen 
minutes at high speed. The resulting sediment is smeared 
upon two or three slides, making rather thick smears, and 
then stained in the usual manner. 



PATHOLOGY AND BACTERIOLOGY 39 

The Albumen Reaction 

In doubtful cases when the microscopic examination of 
the sputum is negative, the albumen reaction is of value. A 
positive albumen reaction is found not only in tuberculosis 
but also in pneumonia, pleurisy with effusion, emphysema 
with cardiac dilatation, gangrene, infarction, and other non- 
tuberculous pulmonary conditions, but never in simple acute 
or chronic bronchitis. 

The value of the reaction consists in the negative out- 
come; if in doubtful cases albumen is persistently absent 
after several examinations, active tuberculosis can, with the 
greatest probability, be excluded. A positive reaction indi- 
cates the presence of tuberculosis only when the other dis- 
eases mentioned above are excluded. 

The albumen test is also a guide in prognosis, for as the 
lung condition improves, the amount of albumen in the spu- 
tum decreases and may finally disappear. 

Technique 

A fresh specimen of sputum is taken and mixed with an 
equal quantity of water, and thoroughly shaken. Several 
drops of acetic acid are added in order to coagulate the mu- 
cus. The solution is allowed to stand ten or fifteen minutes, 
being frequently shaken during the time. It is then filtered. 
The process is again repeated one or more times until a clear 
filtrate is obtained, and this filtrate is examined for albumen 
by one of the usual methods used in testing the urine for 
albumen. 

If albumen is present a cloudiness occurs or a curdy pre- 
cipitate (if the boiling test is employed) which, on standing, 
settles to the bottom of the tube. If mucus should happen 
to be present, cloudiness may appear, but the reaction is not 
curdy and does not settle on standing. 

For a quantitative test the following procedure can be 
employed : 

Take a graduated centrifuge tube of 15 c.c/s capacity. 
Fill to the iy 2 c.c. mark with acetic acid. Add potassium 
ferocyanide solution (1 to 20) up to the 5 c.c. mark. Next 



40 PULMONARY TUBERCULOSIS 

add sputum up to the 15 c.c. mark and centrifuge for ten 
minutes at 1000 revolutions. Each 1/10 of a c.c. of precipi- 
tate equals 1/60 of one per cent, of albumen. 

The Complement Fixation Test 

This test similar in method to that of the Wasserman 
reaction for syphilis — the antigen only being different and 
composed of extract from tubercle bacilli cultures — has been 
employed both in the diagnosis and prognosis of tuber- 
culosis. 

There is a difference of opinion, however, as to its value 
in diagnosis ; while some investigators consider a positive 
reaction as indicating active tuberculosis, others consider 
it as only indicating a tuberculous infection. In active cases 
it may be negative and in non-tuberculous cases positive. 

The test requires considerable laboratory technique and 
experience, and in consequence, and from the difference of 
opinion as to its value, one would only exceptionally employ 
it in the diagnosis of suspected cases of tuberculosis. 

It is hardly necessary to add that when the sputum is ex- 
amined in the ordinary way, a single negative result is not 
conclusive evidence that tuberculosis does not exist if there 
are suspicious or definite symptoms and physical signs. 
Under such circumstances one would not infrequently be 
deceived if he rested content with a single negative examin- 
ation. The sputum should be examined several times by 
the ordinary method, or by one of the two methods given 
above, before a definite conclusion is made that the sputum 
is bacilli-free ; and even then, if there are definite symptoms 
and signs not referable to other cases, a tentative diagnosis 
of tuberculosis should be made. In the medical service of 
the army seven examinations of the sputum are required 
before it is pronounced negative. 

Channels of Entrance of the Tubercle Bacillus 

There are three manifest portals of entry, namely: (a) 
inhalation, through the respiratory tract; (b) ingestion, 
through the digestive tract; and (c) inoculation, through 



PATHOLOGY AND BACTERIOLOGY 41 

the skin. The latter is the least important, and as far as we 
know plays little part in the spread of tuberculosis. Of the 
other two channels of infection — inhalation and ingestion — 
it is still an undetermined question which is the more fre- 
quent path, and moreover there may be other modes of 
transmission of which we are as yet ignorant. 

Action of the Tubercle Bacillus. History of the Tubercle 

When the tubercle bacilli have gained entrance into the 
lungs by one or the other route, they may (a) be destroyed 
and leave no evidence of their visit, or (b) remain inactive 
indefinitely or for the lifetime of the individual, or (c) they 
may produce certain inflammatory changes peculiar to their 
specific nature, just as other irritants or specific bacteria 
cause inflammatory phenomena peculiar to their specific 
influence. As with all forms of inflammation, we may have 
resolution, necrosis or ulceration, and a reparative tendency, 
as the formations of fibrous tissue. The tubercle bacillus by 
its irritant effect either gives rise to the formation of the 
characteristic tubercle, composed of epitheloid, lymphoid 
and generally giant cells with a reticulum of fibrous tissue ; 
or else to a diffuse tuberculous infiltration with few if any 
distinct tuberculous nodules; or to a tuberculous exudative 
inflammation, as in tuberculous pneumonia. 

Individual tubercles coalesce and form a nodule or con- 
glomerate tubercle, and when a certain stage is reached in 
its development, degeneration or necrosis takes place in its 
center, of a specific form called caseation or softening. This 
caseation is one of the characteristics of all forms of tuber- 
culous inflammation in the lungs. In acute or primary 
tuberculosis this softening progresses uninterruptedly with 
little or no attempt at repair, but in the chronic form which 
is now commonly believed to be the activation of a former 
childhood infection, nature attempts to limit or strangle the 
tuberculous focus by fibrosis, the formation of connective 
tissue, and this is the way in which healing takes place. The 
tuberculous tissue or tubercle may be directly transformed 
into fibrous tissue, the most perfect form of healing, but this, 



42 PULMONARY TUBERCULOSIS 

unfortunately, does not often happen after the disease has 
become established. The caseous mass may become calci- 
fied to a greater or less extent, thus limiting its destructive 
influence, or it may be surrounded by a fibrous envelope, 
encapsulated. Within this envelope, however, there are 
often virulent tubercle bacilli, which may burst their bonds 
and produce further disease; or the escaped bacilli may enter 
the blood stream and acute miliary tuberculosis ensue. 

Caseation and fibrosis do not usually go on separately, but 
simultaneously, and the result depends upon which process 
finally becomes supreme. The formation of fibrous tissue 
generally takes place at one; part of the tuberculous area, 
while the disease slowly spreads at another. When exten- 
sive caseation or softening occurs, cavities are formed. In 
active tuberculosis the toxin of the tubercle bacillus pro- 
duces, as in other infections, certain constitutional disturb- 
ances, such as fever, rapid pulse, loss of weight and strength, 
and other evidences of a systemic infection. 

In quiescent cases, however, we may have very extensive 
disease with little or no disturbance of the general health; 
the individual may have the appearance of perfect health, 
may be able to follow his usual mode of life, and feel as well 
as ever. 

The tubercle bacillus cannot be destroyed in situ, although 
many attempts have been made to do so. Likewise, innum- 
erable attempts have been made to directly excite the forma- 
tion of connective tissue, but none of the especial methods 
tried have been successful. The only hope of arresting the 
disease is to aid nature in her efforts to form fibrosis, and 
the only successful method of accomplishing this is the gen- 
eral plan of increasing and maintaining the general resist- 
ance of the individual by all the means included in the "open- 
air" treatment. 

Post Mortem Appearances of Tuberculous Lungs 

The changes seen in the lungs of one who has succumbed 
from tuberculosis are varied, depending upon the form and 
stage of the disease. In acute miliary tuberculosis, the lungs 



ggfe^ 




■ 


jg' ^^ 


yjB 


wStfedlSi^HE^ 




iiip^' 


^^W^^i^F'^l 


^SBufc. ; > 


fgaa^^j^S^^B 




^3p^^s 




^ES^^ 


\ : ;:- 



Fig. 8. "Both upper lobes contain cavities and large amounts of 
fibrous tissue. Section of left lung illustrated shows upper lobe 
converted almost entirely into fibrous tissue with several small 
cavities. Caseated tubercles in the lower lobe." 

From U. S. Army General Hospital, Fort Bayard, N. M. 



PATHOLOGY AND BACTERIOLOGY 43 

are studded with nodules of miliary tubercles, and there is 
general congestion. In acute tuberculous pneumonia, we 
have the characteristic exudative changes, as in non-tuber- 
culous pneumonia, and, in addition, caseation — softening — 
and the production of cavities. In the more common fibro- 
caseous form, we find tubercles or nodules, areas of inflam- 
matory infiltration or consolidation, with caseous — soften- 
ing — ulceration, the formation of cavities, and the produc- 
tion of connective tissue — fibrosis — in the attempt to arrest 
or limit the disease. The longer the disease has existed and 
progressed, the greater the destructive changes as indicated, 
for example, in huge cavities. (Fig. 8.) 

Mixed Infection 

The tuberculous lesions offer a favorable medium for other 
micro-organisms, and in more or less advanced cases, vari- 
ous other pathogenic bacteria are frequently found, such as 
the streptococcus, pneumococcus, staphylococcus, and the 
influenza bacillus, in friendly companionship with the tuber- 
cle bacillus. This alliance makes a bad matter worse and 
by their united toxic effect intensifies the symptoms. The 
fight then becomes one between the allied armies of the 
tubercle bacillus and the other pathogenic organisms, and 
the army of the resisting host. 

Extension of the Disease 

From the initial focus the tubercle bacilli may be carried 
to other parts of the lung or to other organs or portions of 
the body. Such migration may take place by the route of 
the blood, the lymphatics, or by the natural channels which 
lead from the diseased focus to other parts of the organ or 
to the bronchi. 

Cavities and Fibrosis 

Softening, if continued, leads to the formation of cavities. 
Several cavities may occur in the same lung, and they may 
unite. If the resistance overcomes the infection, the cavi- 
ties may cease to grow; the destroyed material is eliminated 



44 PULMONARY TUBERCULOSIS 

and cicatricial tissue may form in the cavity walls — a repara- 
tive process. If this fibrosis predominates, we eventually 
see the cavity filled with a thick fibroid mass, and contrac- 
tion takes place. The predominance of the fibroid process 
may exist from the first and form the characteristic feature 
of the disease. When this happens, the progress of the 
disease is slow and the constitutional symptoms compara- 
tively slight, dyspnoea being the most prominent symptom. 
When fibrosis is the chief pathological feature, the name 
fibroid phthisis or fibroid tuberculosis is given to the disease. 

True Healing 

Genuine healing can only be said to have occurred when 
all caseous material is destroyed and calcified deposits or 
connective tissue replaces it. The healed focus then has the 
appearance of a puckered cicatrix. Such evidence of healing 
is often found in autopsies of adults who have died of dis- 
eases other than tuberculosis, as also calcification of adja- 
cent lymphatic nodes. Encapsulation of the caseous mas 
is not true healing, though it is an arrest of the disease, for 
living tubercle bacilli may be contained within the encapsu- 
lating envelope. 

Cause of Hemorrhage 

The slight or moderate hemorrhages which occur in one- 
half or more of all cases of pulmonary tuberculosis generally 
result from the rupture, through ulceration, of a small ves- 
sel in the diseased area, or from exudation. Extensive, and 
often fatal hemorrhages are generally caused by the rupture 
of an aneurysmal enlargement of a vessel projecting into a 
cavity. 

Infection and Period of Incubation 

How long after the implantation of the tubercle bacillus 
acute manifestations of the disease occur, we do not know. 
We know, however, that the development of the infection 
is generally slow; months or years may elapse before active 



PATHOLOGY AND BACTERIOLOGY 45 

symptoms appear, or they may never occur. We believe 
also that infection is not caused by a transitory exposure to 
the bacillus, but by a continuous and oft-repeated one. 
Hence we call tuberculosis a house disease, for in the house 
where there is one individual suffering from the disease, 
others, especially children, who are constantly associated 
with him are more likely to become infected, as investigation 
and experience have shown. 

Predisposition: Acquired; Inherited 

(a) Acquired: 

Not every one, however long he may be exposed to the 
tubercle bacillus, becomes actively infected. In order that 
this may happen, one must have an inherited or acquired 
predisposition. We can only guess as to what causes this 
predisposition or receptive state. In general one can pred- 
icate that whatever influence, long-acting, which lowers the 
normal resistance, produces a favorable soil for the bacillus. 
an acquired predisposition. Such influences are legion: un- 
wholesome conditions of living and working, dusty occupa- 
tions, lack of sunlight and fresh air, over-fatigue, under-feed- 
ing, insufficient rest and sleep, are some of the chief of these 
influences. Certain diseases, as recurrent bronchitis, meas- 
les, whooping cough, the "grippe," diabetes, also appear to 
be predisposing influences. As the majority of adults have 
some tuberculous infection, and yet so many escape the ac- 
tive disease, it is evident that the difference in individuals 
as to their susceptibility depends upon the resistance of their 
tissues rather than upon their resistance to infection. 

(b) Inherited: 

What part inheritance plays in the receptivity of the or- 
ganism we cannot say. Of course, the old idea of the direct 
inheritance of the disease is no longer tenable in the light 
of our present knowledge of its infective nature. The fre- 
quency, however, with which tuberculosis occurs in those of 
tuberculous parentage would seem to indicate the prob- 
ability of an inherited susceptibility. Nevertheless, this is 
by no means certain, and it may only mean that a weakened 



46 PULMONARY TUBERCULOSIS 

body is inherited from those debilitated by a wasting dis- 
ease, like tuberculosis, and hence the organism is less resist- 
ant to tuberculous infection, to which it is more likely to be 
exposed than to any other infection. "It seems perfectly 
plain," says Davenport I considering the question from an 
eugenic standpoint, "that death from tuberculosis is the re- 
sult of infection added to natural and acquired non-resist- 
ance." It is a significant fact, bearing upon this question 
of inheritance, that when calves are removed, immediately 
after birth, from their tuberculous mothers, they grow up 
into healthy animals, and there seems no reason why this 
should not happen in the case of a child born of a tuber- 
culous mother. 

Acute Tuberculosis 

Generally in speaking of pulmonary tuberculosis, one re- 
fers to the chronic fibro-caseous form; but, as in all inflam- 
matory conditions, we have also acute tuberculosis in which 
the caseous element practically alone exists, and the disease 
is purely destructive and acute from start to finish. There 
is no resistance on the part of the organism and the infec- 
tion has its own way without hindrance. We have the 
lobar-pneumonic and the broncho-pneumonic forms. Acute 
miliary tuberculosis stands rather in a class by itself. 

Acute Miliary Tuberculosis 

Acute miliary tuberculosis is always a secondary infection 
from a pre-existing tuberculous focus somewhere in the 
body, from which there is an eruption of tubercle bacilli into 
the blood stream which carries them to the various organs 
of the body. This untoward event may happen as the ter- 
minal stage of a chronic tuberculosis, or may occur in an 
individual in which the original disease appeared to have 
been arrested or was in a quiescent condition. 

It is often quite impossible to make a diagnosis of acute 
miliary tuberculosis, the physical signs are so indeterminate. 

1 "Heredity in Relation to Eugenics," by Charles Benedict Davenport, New- 
York, 1913. 



PATHOLOGY AND BACTERIOLOGY 47 

It resembles typhoid fever and can be mistaken for it. It 
also simulates acute bronchitis of the smaller tubes. One 
should seek for evidence of tuberculosis in other parts of the 
body. The marked discrepancy between the physical signs 
and the symptoms of extreme dyspnoea, cyanosis, great 
prostration, and the lower and less continuous temperature 
with the one distinctive physical sign of fine, moist rales 
throughout the chest, heard perhaps only after cough, are 
the most important guides to diagnosis. 

It is always acute and almost invariably fatal. It is the 
overwhelming toxic influence of the bacilli which produces 
the profound depression and the fatal issue. It is the drive 
of a victorious invading army overcoming all resistance. It 
runs its course in from a few days to a few weeks. 

The treatment can only be symptomatic. An example : — 
A patient came to my clinic upon Tuesday with great pros- 
tration and fever. Upon physical examination only fine, 
moist rales were found in his chest. He was referred to the 
hospital where he died on the following Friday. The au- 
topsy revealed general acute miliary tuberculosis. Fortu- 
nately, this dire form of tuberculosis is not common, but in 
cases resembling typhoid fever, when the Widal reaction is 
negative, and other signs of the disease are absent, acute 
miliary tuberculosis should be borne in mind. 

Acute Lobar-pneumonic Tuberculosis 

In this form of acute tuberculosis the general symptoms 
and physical signs so nearly simulate ordinary lobar-pneu- 
monia that in the early stages it is quite impossible to make 
a differential diagnosis unless, fortunately, tubercle bacilli 
are detected in the sputum, which, however, is rarely the 
case in the early stage of the disease. One becomes sus- 
picious when resolution does not occur at the usual time ; 
but even then the case may be regarded as one of delayed 
resolution. As time goes on, however, the real nature of 
the disease becomes revealed. The fever continues ; flesh 
and strength rapidly fail; the expectoration becomes more 
profuse and purulent; and spots of softening in the con- 



NL 



48 PULMONARY TUBERCULOSIS 

solidated lung followed by the formation of cavities are 
detected. Tubercle bacilli will be found in the sputum, if 
they have not appeared before. The disease may proceed 
steadily on without remission, and the fatal end come in a 
few weeks. On the other hand, the severer symptoms may 
abate and the case become subacute and be prolonged for 
from two to six months. In every case of pneumonia one 
should always bear in mind the possibility of tuberculosis. 

Acute Broncho-pneumonic Tuberculosis 
This is the more common form of acute tuberculosis and 
is the one to which the name of "galloping consumption" 
has been given on account of the rapidity of its course. The 
clinical picture is quite different from that of the previous 
form, but the diagnosis in the early stage is equally difficult. 
The symptoms are not as pronounced or severe as in the 
lobar form. 

It is very common in childhood and youth, following 
measles and whooping cough, or as a complication of 
"grippe," typhoid fever and diabetes. It may also follow 
hemoptysis. The symptoms and physical signs are at first 
those of an ordinary broncho-pneumonia. In the beginning 
it may resemble an attack of "grippe." The advance is 
rapid. Soon we find areas of consolidation with moist rales, 
shortly followed by softening and the appearance of tuber- 
cle bacilli in the purulent expectoration. The symptoms are 
marked and markedly out of proportion to the physical signs, 
which is a diagnostic point. There is rapid emaciation; ex- 
treme prostration; night sweats; dyspnoea, anorexia, severe 
cough and continued high fever. The course of the disease 
is generally from two to six months, or it may be only a 
matter of weeks. The end generally comes from exhaustion, 
or meningitis, or hemorrhage may hasten it. As in the pre- 
vious form, the acute symptoms may practically subside, 
and a more or less chronic stage supervene, but recovery is 
very rare. 

Age Period and Resistance 
As with most other infectious diseases, pulmonary tuber- 
culosis occurs most frequently in youth and early adult life, 



PATHOLOGY AND BACTERIOLOGY 49 

the most common age period being from fifteen to thirty-five 
or forty years of age, although no age is exempt from it. 
Infants and young children show the least resistance, and 
in later life, after fifty years of age, the resistance is again 
lowered, although the disease at this age period has a tend- 
ency to be very chronic. The resistance is greatest between 
twenty-five and fifty years of age. 

The Common Form of Tuberculosis 

The chronic or fibro-caseous form of pulmonary tuber- 
culosis is the most common one and is that with which we 
shall hereafter have to deal. It is the type to which we com- 
monly apply the term "consumption." As the name "fibro- 
caseous" indicates, the two processes, caseation — destruc- 
tion, — and fibrosis — repair, healing — go on together. The 
opposing foes, the infection and the resistance, have en- 
trenched themselves for a long war. Many sallies take place 
from one or the other side ; and as one or the other opposing 
forces holds the ground taken and steadily advances, so the 
final issue will be determined. If the tissues of the body are 
able to restrict and limit the growth of the bacilli and their 
advance into new country, and overcome the baleful effects 
of the toxins, then victory is assured and the disease ar- 
rested. All treatment can do is to equip the resistant powers 
of the body to do their best work. Treatment furnishes the 
munitions ; resistance must use them. 



CHAPTER IV 
DIAGNOSIS 

" Find out the cause of this effect." 

" Or rather say the cause of this defect." 

" For this effect defective comes by cause." 

Hamlet. Act II. Sc. 2 

" The Physician ought in the first place to endeavor to ascertain the nature 
and state of the disease by the common symptoms alone." 

John Forbes. 



What We Mean By Early Diagnosis 

When we speak of early diagnosis we mean the earliest 
moment at which we can detect clinical or active tubercu- 
losis. Truly incipient tuberculous infection gives no symp- 
toms and consequently we have no means of detecting it 
except possibly at times by the Roentgen ray, nor is it neces- 
sary, for without symptoms there is no impairment of health 
and hence no treatment is required. 

Early Diagnosis 

The early diagnosis of clinical or active pulmonary tuber- 
culosis is easy or hard very much as one goes about it. Gen- 
erally, I believe, the physician will be able to make a definite 
or probable diagnosis if he diligently studies his patient's 
condition in a methodical manner, correlating and combin- 
ing the symptoms and carefully weighing their evidence. 
"Mistakes," says Hamman, "are due far more commonly to 
carelessness than to the difficulty of diagnostic methods." 
The physician must ever bear in mind that the symptoms 
usually reveal more than do the physical signs, which are so 
often indefinite. If at the first examination he is unable to 
arrive at a conclusion, he can keep the patient under obser- 
vation and subsequent examinations may resolve the doubt. 

50 



DIAGNOSIS 51 

Suspicious Symptoms 

What are the indications which would lead one to suspect 
tuberculosis? There are a number of suspicious symptoms, 
any one or several of which suggest it: 

(a) A persistent cough, which may be and often is so 
slight — perhaps occurring only in the morning — that it is 
not admitted by the patient except upon careful questioning. 
"When there is a long persistent and otherwise unexplained 
cough," says Wilson, "accompanied by either a subnormal 
temperature or one that rises slightly in the afternoon a 
probable diagnosis of tuberculosis should be made." 

(b) A loss of bodily vigor or strength; one becomes more 
easily fatigued than was his wont; as the patient often ex- 
presses it, he has "lost his courage," — he doesn't feel up to 
his work. 

(c) A loss of weight which may be so slight that the pa- 
tient is unaware of it until the scales prove it. 

(d) A slight and persistent rise of temperature in the 
afternoon. 

(e) A rapid pulse persistently above the normal in fre- 
quency, not always present, however, but generally so in 
active tuberculosis. 

(f) Slight shortness of breath on exertion. 

(g) Loss of appetite not infrequently accompanied by 
digestive disturbances. 

(h) Pain in the chest, frequently the only symptom which 
brings the patient to the physician. I have not found this 
symptom of much importance in indicating any tuberculous 
lesion, but it should always be followed up by a careful ex- 
amination. Says Norris : "There are four easily ascer- 
tained and highly suggestive symptoms, the existence of 
which should always arouse our suspicion, unless their pres- 
ence can be explained upon other grounds. They are: (1) 
rapid pulse; (2) evening rise of temperature; (3) loss of 
weight; (4) cough"; and I would add a fifth, namely, loss of 
strength. "The protracted existence of any two of these 
symptoms," continues Norris, "requires a good cause to be 
shown why the diagnosis of pulmonary tuberculosis should 
not be made." 



52 PULMONARY TUBERCULOSIS 

"Always say three things," says Gee, "to a patient whom 
you suspect to be tuberculous" : 

(i) "Get yourself weighed, by the same machine each 
time, to see if you are losing weight." 

(2) "Use a thermometer two or three times each evening 
to see if there is any fever." 

(3) "Save your sputa to be tested (for bacilli)." 
Hemoptysis is a symptom which almost invariably brings 

the patient to the. physician, for there is nothing that alarms 
him more. It may be slight, only "streaked sputum," or it 
may be a mouthful or more. It is the nearest approach to 
a pathognomonic symptom, and unless a definite source in 
the upper respiratory tract is discovered, or a cardiac lesion 
is found, it should be taken to mean pulmonary tuberculosis 
even if no physical signs are detected and the patient other- 
wise appears to be in good health. For example : — A stu- 
dent came to me with the history of a slight hemoptysis 
after some unusual exertion. He had no other symptoms, 
and, so far as he knew, was perfectly well. There were no 
abnormal physical signs. He continued in his work and no 
other symptoms developed. Six months later he had an- 
other similar experience, again from some unusual exertion, 
and again there were no other symptoms or signs. An 
X-ray picture, however, was taken which showed a small 
spot in one lung. He was sent to a sanatorium and later 
discharged with the report that they could find nothing the 
matter with him. 

There are various other slight suggestive symptoms which 
should demand an examination of the lungs, for, as Lawrason 
Brown well says, "in few other serious diseases do we have 
to depend so much upon slight symptoms for early diag- 
nosis." Such other symptoms are (1) chilliness, complained 
of after some slight exposure to cold or wet or a draft of 
air; (2) undue nervousness, which is often considered only a 
neurasthenic symptom; (3) pain and stiffness in the joints; 
(4) in women amenorrhcea, although this does not usually 
occur in the incipient stages; (5) sweating after slight exer- 
tion; (6) anaemia; (7) recurring colds; (8) persistent or in- 
termittent hoarseness; (9) various digestive disturbances: 



DIAGNOSIS 53 

Fistula-in-ano is a tell-tale symptom, and the diagnosis of 
malaria has been made, whereas the supposed malarial symp- 
toms were really those of the toxaemia of an active tuber- 
culosis. 

Sometimes one may come for an examination of the lungs, 
as many do now, presenting no evidence that the disease 
exists, but merely to see if he is "all right." Having deter- 
mined then, for one reason or another, to make an examina- 
tion of the person as to tuberculosis, the first step is to ob- 
tain the history, past and present, and follow up all clues. 
For the sake of method and thoroughness, a definite plan 
or scheme should be followed in doing this, and there are 
many such excellent' outlines. Some have the fault, in my 
opinion, of being too redundant. My own is as follows : 

Scheme of Examination 

Name 

Date Residence 

Age M. S. W. Occupation Race 

Family History 

Exposure to Infection 

Past History 

Habits Venereal Alcohol 

Tobacco 

Present Illness : date and mode of onset. What definite thing does the 
patient complain of? 

Cough Appetite 

Expectoration Digestion 

Loss of Weight; of Strength Pain 

Dyspnoea Ability to work 

Night Sweats Menstruation 

Hemoptysis Fever 

A routine procedure in the examination is of obvious ad- 
vantage in eliciting certain definite facts bearing upon a 
possible tuberculosis, but at the same time the patient should 
always be allowed to tell his own story in his own way 
which will not infrequently bring out important evidence 
not obtained by the questionnaire. Every circumstance in 
the patient's life, however unimportant it may seem in itself, 
may, when taken with other evidence, aid in the diagnosis ; 
the name even, indicating the nationality, may suggest the 
conditions under which the patient has previously lived. So 
may the age, residence and domestic relations have a bear- 
ing upon both diagnosis and progrosis. 



54 PULMONARY TUBERCULOSIS 

Occupation 

The occupation is significant. Is it an indoor or outdoor 
one? Is it pursued under a favorable or unfavorable en- 
vironment? Is it, for example, a dusty occupation? For 
the incidence of tuberculosis is materially greater in dusty 
occupations, especially where the dust is metallic or mineral. 
Is it an occupation which requires excessive mental or phys- 
ical demands and close confinement? One which does not 
allow proper time or opportunity for meals, rest, fresh air 
and recreation? 

Family History 

If there is a history of tuberculosis on the paternal or ma- 
ternal sides indicating a possible inherited predisposition, it 
is a help ; but if negative it is of little importance. The fam- 
ily history, however, if one has time to follow it up, and the 
patient knows it, will tell us something of the vigor, longev- 
ity and tendencies of the family, stock. Some families are 
apparently inclined to certain weaknesses, or diseases, such 
as bronchitis, digestive disturbances, an unstable nervous 
system, rheumatism, etc., we can also learn something of 
the mental and physical traits the patient has inherited or 
what defects have been handed down to him. 

Exposure to Infection 

A history of exposure to a tuberculous infection, long con- 
tinued and close, as from a case in the family, is of far 
greater importance than the fact of family inheritance, "than 
the fact," as Brown says, "that the forebear of the patient, 
one whom he has never seen, has had or died of tubercu- 
losis"; for investigation has shown that when one case of 
tuberculosis exists in the family, it is more than likely that 
other members of the same family may acquire the infection. 
Not infrequently, also, prolonged and intimate association 
with an active tuberculous individual in workshop, factory 
or office has apparently led to the communication of the 
disease from the infected person to the well; for example, 
a young woman, suffering from tuberculosis, a secretary in 



DIAGNOSIS 55 

an office, was apparently infected by her tuberculous em- 
ployer who was careless in the disposal of his sputum. 

Past History 

Under this head, we may learn little or much, depending 
upon the inquisitiveness of the physician and the responsive- 
ness and intelligence of the patient. What we desire to 
learn is the life history of the patient in childhood and adult 
life up to the time of examination. We wish to know what 
children's diseases he had, particularly measles and whooping 
cough, for there is evidence to show that these two infec- 
tions render the lungs more susceptible to a tuberculous in- 
fection or the activation of an old latent infection. Was he 
a vigorous or sickly child? What was his environment and 
nurture in childhood and youth? In adult life did he suffer 
from any serious disease, such as typhoid fever, which some- 
times is not typhoid fever at all but the awakening into ac- 
tivity of a latent tuberculous infection which again sub- 
sides ? Such, also, may have been the real nature of a sup- 
posed attack of influenza. Has he ever had pleurisy, which, 
as we know, is secondary to a tuberculous infection in the 
majority of cases? Other suggestive diseases are recurring 
bronchitis, broncho-pneumonia, diabetes, and neurasthenia. 
One should also inquire into the past or present existence of 
syphilis which is sometimes associated with tuberculosis and 
is a predisposing cause thereto, and is also sometimes mis- 
taken for the latter disease. If any doubt exists a Wasser- 
mann test should be made. 

Habits 

From this inquiry, we learn the patient's routine of life, and 
whatever excesses he may have indulged in, although he will 
generally seek to minimize any bad habits in order to make 
out a good story. The use of alcohol, either habitually or 
spasmodically, is an important question to determine, for, as 
some one has said, "alcohol makes the bed of the consump- 
tive," and its constant employment undoubtedly lowers the 
resistance ; moreover, it is likely to interfere with proper and 
tegular taking of food. As to tobacco, I have never been 



56 PULMONARY TUBERCULOSIS 

able to determine that it has any special influence as a causa- 
tive factor, unless used in excess, or the smoke is inhaled, as 
with cigarette smoking. I have never seen a moderate use 
of tobacco with patients accustomed to it do harm unless 
there was some special contraindication. 

Present Illness 

Under this head we seek to learn what symptom the pa- 
tient first noticed which suggested to him the possibility of 
tuberculosis and when this first occurred. Hawes z thinks 
it better to ask the patient when he last felt perfectly well 
rather than when he first felt sick. As to the first symp- 
tom observed — the patient will generally give one or more 
of those enumerated in the beginning of the chapter which 
may here be repeated: (a) A persistent cough or cold with a 
little expectoration; (b) loss of weight; (c) loss of strength 
or nervous energy; (d) slight dyspnoea on exertion; (e) 
hemoptysis, generally slight; (f) chilliness followed by flush- 
ing or a feeling of undue warmth, indicative of fever; (g) 
pain in the chest, or pain referred to the shoulder blade; 
(h) hoarseness; (i) loss of appetite with digestive disturb- 
ances, all of which are specifically inquired into by the aid 
of the questionnaire in the scheme. 

Of all the symptoms, I agree with Hawes that there is no 
more common one than "loss of ambition or energy." As 
one patient expressed it, he had lost all his "ginger." Again, 
the patient will date the beginning of his trouble from an 
attack of influenza, bronchitis, pleurisy or pneumonia. One 
must be sure that correct answers are obtained from the 
specific questions; for example, the patient may at first say 
that he has no cough or expectoration, but on careful in- 
quiry we may elicit the fact that he has to "clear his throat" 
in the morning and raises a "little ball of sputum"; and in 
the "ability to work" he may not feel able to work, but yet is 
working from necessity. 

While obtaining the history as outlined above, the keen 
physician will have learned much about the general character 
and physical condition of his patient by carefully observing 

1 "Early Pulmonary Tuberculosis," J. B. Hawes 2d, Wm. Wood & Co., 
New York, 1913. 



DIAGNOSIS 



57 



his general appearance, actions, nervous condition, manner 
of answering questions, etc. 

Importance of Symptoms 

In early cases of pulmonary tuberculosis, one cannot be 
too painstaking in eliciting and studying the symptoms; for 
upon them we shall have to depend largely and sometimes 
entirely for our diagnosis. It must always be remembered 
that "symptoms frequently appear when no physical signs 
can be detected in the lungs." To depend upon indefinite, 
doubtful physical signs to the neglect of a careful study of 
the symptoms will often lead to an erroneous diagnosis. 
On the other hand, also, remember that physical signs with- 
out symptoms mean only that there is a tuberculous infec- 
tion and not active clinical tuberculosis, and therefore, be- 
cause physical signs are detected and there is no other evi- 
dence that the patient is ill, he should not be removed from 
his occupation and family life, which may "blast his whole 
career and life, prevent marriage and self-support." This, 
unfortunately, has sometimes happened in the eagerness 
to make an early diagnosis from physical signs alone with- 
out carefully considering the symptoms. r 

Physical Examination 

We come now to the physical examination of the patient, 
and in order to proceed methodically, it is well to have a plan 
or scheme, with a diagram of the chest upon which to note 
our findings. The following simple one is that which I find 
useful (Fig. 9). 




.big. 9. Diagram for indicating physical findings 



58 PULMONARY TUBERCULOSIS 

Examination of the Chest 

(a) Position of the Patient: — 

The patient should, in all cases, be stripped to the waist, 
with a sheet or some covering thrown about him, and seated 
upon a revolving stool. It takes considerable time for a 
careful examination and it is less tiresome both for the pa- 
tient and physician to be seated than to stand. The arms 
should hang loosely by the side when examining the front 
of the chest, and when examining the back the arms should 
be folded or one hand placed upon the opposite shoulder 
when examining one or the other space between the scapula 
and the vertebrae for by this maneuver the scapula is pulled 
outward and one obtains more space between it and the 
spinal column. In examining the axilla, the hand should be 
placed upon the head. 

(b) Inspection: 

In inspecting the chest one should not be content with 
looking at it from the front, but also from the side and over 
the patient's shoulders. One should notice (a) the shape of 
the chest, as a whole, giving especial attention to the spaces 
above and below the clavicle to see whether there is more 
depression on one side than the other; (b) the appearance 
of the skin, its color, prominence of the veins, and any ex- 
crescences, such as swellings, and the neck should also be 
examined in this connection for scars indicating former 
adenitis, or for existing glands; (c) the respiratory move- 
ments, not only of the upper part of the chest, but also the 
diaphragmatic respiration. Particularly to be noted is de- 
layed expansion, or less movement at one apex than at the 
other, which, when one can be sure of it, is a sign of value 
in early diagnosis. 

Pulse and Respiration 

The pulse and respiration should not be taken until the 
the patient has had time to rest and become accustomed to 
the situation. If taken when he is more or less excited upon 



DIAGNOSIS 59 

the first visit to the physician, they will generally be above 
the normal rate. A much increased pulse rate, as has been 
observed, is of material significance, but in my experience 
rapid respiration is of less importance, although it is sug- 
gestive. 

Examination of the Upper Respiratory Tract 

Before or after the physical examination of the chest, the 
upper respiratory tract should be investigated: — the nose, 
pharynx and larynx, and their condition and color of the 
mucus membranes noted. An anaemic, relaxed mucus 
membrane in these parts is often observed in pulmonary 
tuberculosis. 

The Weight 

First, the weight is taken with accurate scales and com- 
pared with the normal weight so far as we can learn it from 
the patient or estimate it. "In the diagnosis of early tuber- 
culosis," says Lindsay, "the weighing machine plays a part 
hardly less important than the stethoscope or the ther- 
mometer, for wasting in some degree is one of the most con- 
stant symptoms." 

The Temperature 

The temperature taken once in the physician's office at 
whatever time the patient happens to be there is of little 
value unless it is ioo° F. or more. To obtain the real tem- 
perature variations, it should be taken at 8 a. m., 12 M., 4 and 
6 p. m. for a period of a week, and the patient can readily be 
instructed to take it himself, or some one in the house can 
do it for him. A constant although slight rise of tempera- 
ture (99. 5° or over) usually occurring in the afternoon, or a 
subnormal temperature if accompanied by a persistently 
rapid pulse is very significant. When these two conditions, 
viz., a slight rise of temperature in the afternoon or a sub- 
normal temperature and a rapid pulse are present and at 
the same time they are accompanied by a little loss of weight 
and strength and undue nervousness, the case for the ex- 



60 PULMONARY TUBERCULOSIS 

istence of pulmonary tuberculosis is a strong one. It is to 
be borne in mind that the above symptoms resemble those 
of neurasthenia and a diagnosis of the latter should not be 
made without a careful investigation as to the condition of 
the lungs. 

Outline of Percussion and Auscultation Sounds 

The following brief sketch of percussion and auscultation 
sounds will refresh one's memory as he proceeds to employ 
them in the next step of the examination. 

Percussion 

Prolonged practice is necessary to acquire skill in the 
practice of percussion. 

The sound which we obtain in percussing the lungs is 
called the percussion note. 

Percussion sounds have certain attributes or characteris- 
tics just as other sounds do, as the sound of a cannon, a 
violin, or a bell. Those attributes are: (a) quality; (b) in- 
tensity or loudness; (c) pitch, — high, low or intermediate; 
(d) duration (of least importance). 

The qualities of sound produced by percussing the chest 
may be included under three divisions : — 

I. Normal vesicular, or clear, — the sound given out by the 
healthy lung. Under this head we may include an abnor- 
mally clear sound called "hyperresonant," found in emphy- 
sema for example. 

II. Dull sound, with the subdivisions: (a) slight dullness, 
(b) moderate dullness; (c) absolute dullness (flatness), pres- 
ent in varying degrees of consolidation, pleural effusions, 
thickened pleura, pulmonary oedema, hemorrhagic infrac- 
tion, and, in general, when the solids or liquids within the 
chest are abnormally increased without increase in the quan- 
tity of air (Flint). 

III. Tympanitic sound: a clear, hollow sound of a drum- 
like quality, such as heard in percussing a distended stom- 
ach or in a pneumothorax. It is devoid of all vesicular 
quality. This sound is elicited in more or less purity in 




Fig. 10. Auenbrugger 



DIAGNOSIS 6 1 

pneumothorax, and in cavities containing air. Varieties of 
tympanitic sounds are: (a) amphoric sound; occurring over 
a pulmonary cavity and in some cases of pneumothorax; 
(b) the cracked-pot sound, most often heard over large 
superficial air-containing cavities, and is the most infallible 
sign of a cavity known; is sometimes found in relaxed and 
infiltrated tissue (pleurisy and pneumonia). 

Pitch: The greater volume of air over which we percuss, 
the lower the pitch, and as the volume or air is diminished, 
pitch rises, like the large and small pipes of an organ; hence 
pitch is lowest in the tympanitic sound and highest in the 
dull sound. The first suggestion of impaired resonance is 
a slight heightening of pitch, a shallower sound: we com- 
monly call it, however, "slight dullness." 

Duration varies inversely with pitch; that is, the higher 
pitch the shorter duration, and vice versa. A deep toned 
bell vibrates longer than a high, shrill toned one. Intensity 
or loudness of sound depends upon thinness of chest walls 
and force of percussion. 

Auenbrugger's dictum (Auenbrugger discovered percus- 
sion and published a treatise upon it in 1761) : — Fig. 10. 

"Sonitus vel altior, vel profundior; vel clarior, vel ob- 
scurior, vel quandoque prope suffocatus deprehenditur." 

" 'The sound (i. e., the percussion sound) is a tone, clear 
or muffled, even to complete privation.' This is the first 
and great distinction. And next, 'the tone is of a pitch 
higher or lower.' Upon these two hang the whole theory 
and practice of percussion." 1 

Auscultation 

Laennec, a celebrated French physician, discovered auscul- 
tation and published his first treatise upon it in 1819. Before 
Laennec, "clinical observation though never blind had been 
always deaf." Fig. 11 

Auscultation of the lungs is practiced with reference to 
three kinds of sounds : — 

I. The sounds of breathing. 

1 Gee "Auscultation and Percussion." London, 1893. 



62 PULMONARY TUBERCULOSIS 

II. The voice sounds. 
III. New or adventitious sounds (rales, friction 
sounds). 
I. The breath sounds: There are three general types of 
breathing, — (a) normal or vesicular; (b) bronchial; (c) 
cavernous. When the breathing is part vesicular and part 
bronchial it is called "broncho-vesicular," or "rough" breath- 
ing or sometimes "harsh." 

(a) Vesicular breathing: Heard over normal lung. It 
may be normal in all respects and yet disease may exist, as 
in slight bronchitis, a few scattered tubercles, and early stage 
of pneumonia. Vesicular breathing may be altered as re- 
gards (a') intensity; (b') rhythm. (a') alterations in inten- 
sity: we may have (i) exaggerated vesicular breathing 
(also called puerile) ; occurs on healthy side of chest when 
the respiratory function of the other side is interfered with, 
e. g., pleuritic effusion, pneumonia. (2) Diminished vesic- 
ular breathing (also called senile). Occurs when there is 
a thin layer of fluid between lungs and chest wall, or a thick- 
ened pleura, in emphysema, and in some cases of tubercu- 
losis. (In large pleural effusions the respiratory sound is 
generally entirely absent.) 

(b') Alterations in rhythm, (1) prolonged expiration; 
occurs for example in emphysema (may or may not be a 
sign of disease). (2) Jerky or cogwheeled respiration, an 
uncertain sign, not of great importance. 

(b) Bronchial breathing (heard normally in an exaggerated 
form over trachea and at level of seventh cervical and upper 
five or six dorsal vertebrae and directly under the lobe of the 
ear). Occurs in disease in the following conditions: (1) 
consolidation of the lungs from whatever cause; (2) some 
cases of pleural effusion; (3) collapse of the lungs ; (4) in 
certain cavities when the conducting bronchi are free. 
(Tubular breathing is an intense bronchial breathing with a 
metallic quality.) 

Br one ho -vesicular or "rough" breathing-. Occurs in differ- 
ent degrees of solidification of the lungs, e. g., in tubercu- 
losis, pneumonia. The essential characteristics of broncho- 




Fig. ii. Laennec 



DIAGNOSIS 63 

vesicular breathing are a lengthening of the expiratory 
sound, and a roughening of both inspiration and expiration, 
and it means that more or less consolidation has taken place, 
(c) Cavernous breathing: Heard over a cavity, and is 
bronchial breathing rendered more intense by the reverbera- 
tion of a cavity. 

II. Voice sounds: Spoken or whispered. We have (a) 
increased vocal resonance, (b) diminished vocal resonance, 
(c) absent vocal resonance, (d) bronchophony — all depend- 
ing upon the condition of the conducting medium. Broncho- 
phony is simply extremely increased vocal resonance, and is 
present under the same conditions as bronchial respiration. 

(a) Increased vocal resonance : Suggests either (1) solidi- 
fication (more or less); or (2) a cavity. (Vocal fremitus 
suggests the same conditions as vocal resonance.) 

(b) Diminished vocal resonance: Suggests either (1) fluid 
in cavity; (2) thickening of pleura; (3) blocking of bronchial 
tubes with secretion; (4) pressure on lungs by tumor or 
aneurysm. 

III. New or adventitious sounds: (Rales and friction 
sounds.) Rales (always a sign of an abnormal or diseased 
condition) are known as dry and moist. 

1. Dry rales — sonorous=low pitched. 

sibilant=high pitched. 
They are pathognomic of bronchitis. 

2. Moist rales — fine (crepitant). 

coarse and of varying sizes between the 
two. 

The terms "sub-mucus," "sub-crepitant," "crepitant," 
"sticky," "crackling" are names applied to varieties of moist 
rales. Crepitant rales may be considered a sub-division of 
fine rales. All moist rales are caused by the passage of air 
through liquid, which may be blood, mucus or serum. We 
have moist rales in bronchitis, oedema, pneumonia, tuber- 
culosis hemorrhagic infarction, during and shortly after an 
hemoptysis, atelectasis. 

Friction sounds or pleural rales indicate pleurisy. Some- 
times we have a coarse rubbing and sometimes an explosion 



6 4 



PULMONARY TUBERCULOSIS 



of fine rales or what sounds like that. They are most com- 
monly heard in the lower axilla. Cough does not affect 
friction sounds. 

It is an economy of time and convenient for subsequent 
reference to indicate upon a diagram of the chest, front and 
back, the abnormal physical signs detected, and for this pur- 
pose some system of signs is necessary. The one I have 
employed for many years is the following which is very sim- 
ple and answers the purpose sufficiently well. It is hardly 
necessary to say that the whole chest should be examined, 
front, back, axillary region and base. It is true that, if 
tuberculous infiltration is present, evidence of it will almost 
always be found either in the supra- or infra-clavicular re- 
gion, the supra-spinous fossa, or the inter-scapular space ; 
still, there are exceptions and one should always examine 
the entire chest. 



Systems of Signs for Recording Findings 



Dullness on Percussion 

Questionable dullness I 

Slight dullness II 

Moderate dullness III 

Marked dullness IIII 

Flatness or intense dullness IIIII 



Dullness on Percussion 
Tympanitic = "O" 
Cracked Pot = "C.P." 



Rales 

If not heard with ordinary respiration 
state with cough — "c c'gh." 

With full inspiration — "c full insp." 

Fine dry "dry clicks" 

Fine, medium or coarse moist rales, in- 
dicate by dots of varying size or small 
circles. 

Sibilant — VV 

Sonorous — VV 

Friction sounds (pleuritic) # # $ 



Respiration 
Diminished or feeble: — "Resp. — ' 

(minus), or > (Dim.) 
Respiration increased = "Resp. + " 

or + + 
Expiratory murmur increased = 

"Exp't'n+." 

Respiration 
Broncho-vesicular Resp. = "B. V. 

(+or++)" 
Bronchial Resp. = "Br." 
Amphoric = "Amph." 
Cavernous = "Cav." 

Voice Sounds 
Vocal resonance dim. = "Voice — 

(minus) or > (dim.)" 
Vocal resonance increased 

or++" 
Bronchophony = "Br'y" 
Tactile Fremitus = T. F. 
Tactile Fremitus increased = T. F. + 

ar++ 
Tactile Fremitus decreased = T. F. > 
Tactile Fremitus absent = T. F. — 

(minus) 



; Voice -f- 



Percussion 



In percussion one should begin with the front of the chest 
and go from below upwards; for at the lower part of the 



DIAGNOSIS 65, 

chest one will generally get the normal resonance, and this 
can be taken as a standard with which to compare the reson- 
ance higher up. Comparatively light percussion is prefer- 
able in front and heavier behind. Sometimes both light and 
heavy percussion in front will better bring out differences in 
resonance if they exist. It must be borne in mind that at 
the right apex there is a physiological difference in the per- 
cussion sound from that at the left apex: it is not so reson- 
ant and of higher pitch, and, moreover, the respiration is 
rougher, or broncho-vesicular in character, and the voice 
sounds decidedly more intense. All this is normal for the 
right apex. As Cabot says, "We find at the apex of the 
right lung in health signs almost exactly identical with those 
of a slight degree of consolidation." In early cases there is 
rarely any dullness. The most that we shall, as a rule, find 
is some slight diminution of resonance and a heightened 
pitch, changes so slight that it is difficult to be sure that they 
exist. 

In making an early diagnosis, percussion will give us but 
little, if any, definite information. When unmistakable dull- 
ness is present, either an old arrested or inactive focus of 
consolidation of appreciable size exists, or, if active, the dis- 
ease has passed beyond the initial stage. Sometimes when 
there is very considerable infiltration in both lungs, the per- 
cussion, although markedly impaired, may be so nearly the 
same on both sides, that one may not recognize that any 
dullness exists, particularly if there are no adventitious 
sounds. A mistake, and quite a natural one for a beginner, 
not infrequently made. 

Auscultation 

It is principally upon auscultation that one must depend 
for physical signs in early diagnosis, and here again such 
auscultatory signs will often be so indefinite that their inter- 
pretation becomes difficult if not impossible. Both in per- 
cussion and auscultation one can better discriminate between 
slight differences in pitch and sound if he has a musical ear. 
Hence the advantage of being able to sing or play upon 



66 PULMONARY TUBERCULOSIS 

some musical instrument or the training of one's ear in listen- 
ing to good pure music. The elder Flint who was a con- 
summate master of auscultation and percussion played the 
violin for years to "preserve the fine sense of pitch with 
which he was endowed." (Pryor.) Laennec, the inventor 
of mediate auscultation, played upon the flute, and Auen- 
brugger, the discoverer of percussion, was passionately de- 
voted to music. 

It does not make so much difference what kind of a stetho- 
scope one uses, provided he becomes accustomed to it. It 
is very much like a sportsman who has become used to his 
own gun: it may have defects, but he has learned to make 
allowances for them, so that he can shoot more accurately 
with it than with a more perfect one with which he is not 
acquainted. So it is with the stethoscope which one con- 
stantly employs. 

First, one studies the respiration; then the voice sounds, 
whispered and spoken, and finally seeks for adventitious 
sounds — rales. These latter, however, may be the first 
abnormality detected, and if localized and constant, they go 
far towards making a definite diagnosis, for they are new 
sounds, while modifications in the respiration are only vari- 
ations of normal sounds and are of uncertain interpretation. 



CHAPTER V 
DIAGNOSIS, CONTINUED 

The Respiration 

In investigating the respiratory sounds one should first 
listen to quiet, ordinary breathing and then to deeper breath- 
ing, the mouth being slightly open; but no audible sound 
should be made in inspiration or expiration. It is often well 
to show the patient how you want him to breathe by doing it 
oneself. It is also a good plan to concentrate one's atten- 
tion on the inspiration alone and then on the expiration. 

The ability to distinguish abnormal respiratory sounds 
must depend upon a clear recognition of the normal vesicu- 
lar murmur, and the advice given by the elder Dr. Bowditch 
nearly seventy-five years ago in his "Young Stethoscopist" 
is excellent advice now: "You cannot study too frequently," 
he says, "or too minutely the respiratory murmur and the 
voice in healthy persons. One of the best exercises you can 
have is the daily examination of three or four individuals 
who are free from thoracic symptoms. . . . For, in addi- 
tion to having accurately learned the character of vesicular 
respiration, you will likewise have prepared yourself for the 
recognition of bronchial respiration and bronchophony when 
they are the result of disease." 

One of the most significant modifications of the respira- 
tory murmur is what Turban calls "rough" breathing, which 
differs from the smooth sound of normal vesicular breathing 
in that it gives one the impression of air passing over a 
roughened surface, like riding in an automobile over a rough 
road in comparison with the easy rolling over a smooth one. 
At the same time, the respiratory murmur may be slightly 
diminished. Following the roughened inspiration, we may 
have a clearly discernible prolonged expiration, which may 

6 7 



68 PULMONARY TUBERCULOSIS 

be more or less bronchial in character. This rough respira- 
tory murmur is considered the earliest auscultatory manifes- 
tation of a tuberculous invasion, and is produced by slight 
inflammatory changes in the bronchioli. 

Broncho-vesicular respiration is about the same thing as 
"rough" breathing considered from a different point of view. 
As the name implies, it is a mixture of the two kinds of mur- 
murs, the bronchial element occurring in the expiration 
which is prolonged. "This sign." says Flint, who introduced 
the name broncho-vesicular in 1856. "represents the different 
degrees of consolidation of the lung between an amount so 
slight as to occasion only the smallest appreciable modifica- 
tion of the respiratory sound, and an amount so great as to 
approximate closely to the degree giving rise to bronchial 
respiration." 

It is well to repeat, that what we may consider a "rough" 
or broncho-vesicular murmur at the right apex, unless much 
exaggerated, is physiological at that apex. and. as Cabot 
says, "we find in the apex of the right lung in health signs 
almost exactly identical with those of a slight degree of 
solidification" and "would mean serious disease if heard over 
similar portions of the left lung." 

I have often had students tell me, in the examination of a 
patient, that they found bronchial respiration in one place 
or another when it did not exist : and. in order to show them 
their mistake. I tell them to listen to normal bronchial 
breathing over the larger bronchial tubes, a little below the 
trachea in front, and at the level of the seventh cervical and 
the upper five or six dorsal vertebrae behind, or under the 
lobe of the ear. and compare the respiratory sound heard 
here with their supposed bronchial breathing. 

Genuine bronchial respiration is not, of course, an early 
sign. Sometimes one detects a definite difference in the 
intensity of the vesicular murmur in the two apices. In one 
apex it may be distinctly less intense. We call it diminished 
or weak respiration : and when one is sure of the observa- 
tion, it is a sign of considerable value in early diagnosis, and 
mav be the onlv one we find. 



DIAGNOSIS, CONTINUED 69 

Cog-wheeled or intermittent breathing in my experience 
is a sign of little value, for one so often hears it when there 
are no other symptoms or signs to indicate any pulmonary 
disease. At all events, when it occurs generally over the 
chest, it is of no importance; but when limited to one or 
both apices it may have some diagnostic value in combina- 
tion with other signs. 

After all is said, slight modifications of the respiratory 
murmur are difficult of detection and of doubtful value. 
"Distinctions" (in the respiratory murmur), says Gee, "which 
correspond with no definite physical condition of lung, make 
a show of profound and accurate knowledge, but really ob- 
scure it. They are idoli theatri." 

The Voice 

In order to make the auscultation of the voice of value, it 
must be fairly resonant, and hence with some persons, espe- 
cially women, when the voice is thin and feeble, the evidence 
obtained from this sign is of little worth. The patient is 
told to utter slowly some sonorous word. I find the simple 
"one" as good as any; others prefer "twenty-three" or 
"ninety-nine." It is to be borne in mind that normally the 
voice sounds are markedly louder at the right apex than at 
the left, and if one finds them of equal intensity at both 
apices, it is an indication that there is some infiltration at the 
left apex. The whispered voice is a more delicate test than 
the spoken one, and when it is of greater intensity and of a 
higher tone, it is indicative of some infiltration. In early 
cases, however, one will seldom be able to discern any ap- 
preciable difference, either in the spoken or whispered voice. 
Later, when there is definite consolidation, bronchophony 
appears over the consolidated area. 

Tactile Fremitus 

Unless there are gross changes in the lungs, the tactile 
fremitus, or vocal thrill, will not be altered. At best it is a 
sign of very secondary importance. 



JO PULMONARY TUBERCULOSIS 

Rales 

Rales are, by far, of the most significance of all the auscul- 
tatory signs, for they are definitely abnormal, and when per- 
sistent and localized, even if but a few and feeble, they have 
far greater weight in making an early diagnosis than any 
deviation in the respiratory murmur. Such rales as one 
hears in early cases are fine moist ones or "crackles," as some 
call them, generally heard only after cough. They are most 
commonly found above and below the clavicles, in the supra- 
spinous fossae behind, and in the upper and middle inter- 
scapular region. 

Although rales may not be theoretically considered the 
earliest physical sign of pulmonary tuberculosis, the great 
majority of physicians will make their diagnosis depend, so 
far as the physical signs are concerned, upon the discovery 
of rales, but they must be persistent and localized. In the 
examination of normal chests I have often found, on the 
first full inspiration, a rale or two, due to the sudden and 
unusual expansion of an atelectic lobule, but such rales dis- 
appear not to return after the first few full inspirations, and, 
therefore, they will not mislead one. One must never forget 
to have the patient cough and then take a full breath im- 
mediately thereafter, for thus rales will appear which would 
otherwise not be detected. Turban mentions the incident 
of a patient who had consulted many doctors and who de- 
cided their diagnostic ability by whether or not they asked 
him to cough during examination. 

One must agree with Hector MacKenzie that "the earliest 
physical sign which is really characteristic is the presence of 
rales," localized rales. They are unmistakable, and they are 
almost pathognomonic. No pains is too great in the en- 
deavor to elicit them. "Not infrequently," says Dr. Bow- 
ditch, "a sound like a simple whistle or a sonorous rale is 
heard under the clavicle, while in the remainder of the chest 
there is a healthy vesicular murmur; this strongly indicates 
the existence of tubercular disease if the patient is suffering 
from a chronic affection, especially if it is connected with 
any other distinctly morbid physical or rational sign." 



DIAGNOSIS, CONTINUED Jl 

In making a physical examination one must not neglect 
the base of the lungs, for occasionally in adults and more 
frequently in children the first physical signs are discovered 
in the base of one or the other lung. With the adult, this 
means one of two things, either that the signs do not mean 
tuberculosis unless there is other corroborative evidence, or 
that there is also disease at the apex of the same lung which 
has not been discovered. If, however, we find evidence of 
basic affection and can find none at the top of the lower lobe, 
then the conclusion must be that the basic disease is not 
tubercular but due to other causes, such as oedema, collapse, 
pleurisy, bronchitis, broncho-pneumonia, bronchiectasis, or, 
possibly, to actinomycosis or syphilis. 

In doubtful cases one should go over the chest a second 
time, allowing the patient to rest between the two examina- 
tions. In this connection it is well to repeat again that in 
every suspected case an examination of the sputum should 
be made and several times repeated if the tubercle bacilli are 
not found upon the first examination. Although one can 
often be morally sure that tuberculosis exists from the symp- 
toms and physical signs, yet absolute certainty can only be 
determined by finding tubercle bacilli in the sputum, for it is 
possible that the symptoms which we regard as indicating 
tuberculosis may be caused by other conditions. "Active 
disease confined to one apex," says Glover I "with a repeat- 
edly negative sputum is not common." 

The albumen reaction of the sputum described upon page 
39 may aid in making a definite diagnosis when the micro- 
scopic examination of the sputum is negative. 

After the most careful physical examination, one will often 
be unable to detect definite evidence of disease, if he bases 
his diagnosis upon physical signs alone; for as Knight, one 
of the most acute observers of our day, truly observes : 
"Variations in the respiratory murmur and slight modifica- 
tions of the percussion note are not enough for a positive 
diagnosis," and "a patient should not be condemned to radi- 
cal treatment upon such insufficient evidence." And as 
1 Quarterly Journal of Medicine, London, July 8, 1915, No. 32. 



*J2 PULMONARY TUBERCULOSIS 

Hammon says, * "Slight apical abnormalities (i. e., slight 
changes in the character of the percussion note and of the 
breath and voice sounds) are evidence of infection and not 
of disease, and taken alone do not decide the diagnosis." It 
is chiefly upon the symptoms that one must depend for an 
early diagnosis, unless he is fortunate enough to discover 
tubercle bacilli in the sputum or detects persistent localized 
rales, or hemoptysis has occurred not referable to any other 
source than the lungs. "Amidst the niceties of our physical 
examinations," says Dr. Bowditch, to whose wisdom I have 
before referred, "we are apt to neglect the rational signs. 
The truth is that he who scoffs at either must necessarily 
be a child in the diagnosis of not a few diseases ; and he who 
cultivates both with the clear, keen-sighted eye of a true ob- 
server and then notes their mutual relations is the truly wise 
physician." If from all the evidence obtained one is unable 
to make a probable diagnosis sufficiently strong to warrant 
active treatment, he must keep his patient under observation 
and make repeated examinations at short intervals. An- 
other point to remember is that the localization of the signs 
is quite as important, if not more so, than their character. 

The following aphorisms of Lawrason Brown of Saranac 
Lake, 1 which are derived from a long and large experience, 
are most valuable guides. "For the beginner in work in 
pulmonary tuberculosis," says Brown, "succinct opinions in 
diagnosis are of great assistance." 

I. "An appearance of ruddy health does not exclude tuber- 
culosis." 

II. "In any patient with constitutional symptoms, no mat- 
ter of what he complains, the possibility of tuberculosis must 
be kept constantly in mind." 

III. "Prolonged contact with tuberculosis may lead to in- 
fection, but debilitating conditions are necessary usually to 
cause this to develop into clinical tuberculosis." 

IV. "Constitutional or general symptoms lead us to a 

*The American Review of Tuberculosis, Vol. I, No. 4, June, 1917. 

1 Journal of the American Association, June 12, 1915, Vol. 64, No. 24, and 
The American Review of Tuberculosis, Vol. I, No. 4, June, 191 7. 



DIAGNOSIS, CONTINUED 73 

diagnosis of tuberculosis, while the localizing symptoms 
point out the organs involved." 

V. "The history or presence of certain complications, as 
fistula in ano, pleurisy, adenitis, a discharging ear, coming on 
painlessly, are all strongly suggestive of tuberculosis." 

VI. "Pleurisy with effusion, not attributable to other 
causes, should be treated for a time as due to tuberculosis." 

VII. "Loss of color, prolonged exposure to tuberculous in- 
fection, especially in childhood, with a history of swollen 
glands at that time, the more recent subjection to debili- 
tating conditions, the presence of unequivocal constitutional 
and localizing symptoms, with or without the aforementioned 
complications, demand a diagnosis of pulmonary tuberculosis 
even though no abnormal physical signs are present in the 
lungs." 

VIII. "A diagnosis, tentative at least, must be made when- 
ever an individual spits a dram or more of blood that cannot 
be proved to be due to other causes (i. e., Mitral stenosis)." 

IX. "Your patients, your friends, your family are as prone 
to contract and develop pulmonary tuberculosis as hundreds 
of others." 

X. "The importance of physical examination in the diag- 
nosis of pulmonary tuberculosis has been over-emphasized." 

XI. "Symptoms are a better and more accurate guide to 
activity than physical signs." 

XII. "Symptoms without physical signs demand treat- 
ment, while physical signs without symptoms require only 
careful watching." 

XIII. "Slight but persistent rise in temperature and in- 
crease in rapidity of pulse are often present early in the dis- 
ease." 

XIV. "Failure to interpret rightly the significance of 
symptoms, to detect the presence of abnormal physical signs 
can be condoned; but failure to ask for and examine the 
sputum repeatedly in any patient with chronic cough is in- 
excusable." 

XV. "Absence of tubercle bacilli in the sputum means 
only that bronchial ulceration has not occurred." 



74 PULMONARY TUBERCULOSIS 

XVI. "No single physical sign is pathognomonic of pul- 
monary tuberculosis.'' 

XVII. "Auscultation and inspection are the most impor- 
tant procedures in the detection of abnormal physical signs, 
and auscultation is more important than inspection." 

XVIII. "The usual weight of a patient who develops pul- 
monary tuberculosis is often ten pounds below the normal 
weight for his height and age." 

XIX. "Changes in the relative lengths, quality, and inten- 
sity of the inspiration and expiration are valuable but less 
easy to detect than rales." 

XX. "The detection of rales by the auscultation of the 
inspiration following cough is the most important procedure 
in the detection of physical signs of early pulmonary tuber- 
culosis." 

XXI. "The importance of any physical sign is greatly 
increased by its persistence in one definite area." 

XXII. "The disease is practically always more extensive 
than the physical signs indicate." 

XXIII. "Abnormal physical signs at one apex should be 
considered as due to pulmonary tuberculosis, until proved 
not to be, while those at the base should be looked on as non- 
tuberculous until definitely proved so." 

XXIV. "When sputum is lacking or when tubercle bacilli 
are absent on repeated examinations the possibility of the 
presence of bronchiectasis, hyperthyroidism, syphilis and in- 
fluenza and more rarely pulmonary tumor and Hodgkin's 
disease should be borne in mind." 

XXV. "It may be impossible to determine definitely the 
presence or absence of clinical tuberculosis." 

The X-Ray in Diagnosis 

There are two other aids that may render a doubtful diag- 
nosis certain: the X-ray and the tuberculin test. In order 
to be of much value the X-ray plate should be made by an 
expert technician who is also skilled in the interpretation of 
the roentgenogram or of the fluoroscopic picture. More- 
over, one must be thoroughly familiar with the X-ray picture 



DIAGNOSIS, CONTINUED 75 

of the normal lungs. Under these circumstances the X-ray 
may "reveal and locate pathological pulmonary changes to 
be detected by no other means particularly paravertebral or 
deep lung tuberculosis where physical signs are absent or in- 
definite" (Brown). It tells us little or nothing, however, as 
to the activity or non-activity of the lesion. And it is to be 
remembered that many healthy persons show abnormalities 
in the apices or elsewhere upon the Roentgen ray plate; 
indeed, it is rare to find an absolutely normal plate of an 
adult's lungs. Moreover, it often reveals more extensive 
disease than the physical signs show. If a tuberculous lesion 
is present the X-ray picture will indicate it by opacities, 
shading or mottling at the apex, or elsewhere, often difficult 
to detect and interpret. The X-ray is only an exceptional 
expedient when all other means fail; generally one can better 
spend his time gaining perfection in diagnosis from the 
symptoms and physical signs than in attempting to become 
skilled in the use of the X-ray or in the interpretation of its 
revelations and it is always to be borne in mind that the 
X-ray tells us nothing certain as to the activity of the disease. 

The Tuberculin Test 

This test, as generally employed, is of two forms: (a) the 
von Pirquet vaccination test and (b) the subcutaneous one. 

(a) The von Pirquet Test. 

This test is chiefly useful with children under five years of 
age. , It consists in slightly scratching the arm, after it has 
been cleaned with alcohol, with a sterilized needle or some 
sharp-pointed instrument, not deep enough, however, to 
draw blood. Three spots are thus scarified and upon two 
of them a drop of full strength old tuberculin (O. T.) is 
placed, while the third is left for a control. After ten min- 
utes what remains of the tuberculin is wiped off and no 
dressing is applied. A reaction, if it occurs, will appear in 
from twenty-four to forty-eight hours, and will be indicated 
by a red raised areola at the site of the vaccination about the 
size of a penny, while the control spot will show nothing. 
As, according to von Pirquet, ninety per cent, of persons 



j6 PULMONARY TUBERCULOSIS 

over fourteen years of age give a positive reaction, the test 
with adults is generally positive and only shows that there 
is a tuberculous lesion somewhere in the body, but tells us 
nothing as to its activity. A negative reaction in general 
indicates the absence of tuberculosis. 

(b) The Subcutaneous Tuberculin Test: 

In this test a minute amount of Koch's old tuberculin 
(O. T.) is employed, which can be prepared by diluting the 
original full strength tuberculin, or the dilutions can be ob- 
tained already made. So many tenths of a c.c. of the diluted 
tuberculin will contain the amount we wish to use. A 
syringe graduated in tenths of a c.c. is employed, and aseptic 
precautions, as with ordinary subcutaneous injections, are 
of course taken. The injections are made preferably in the 
back below the angle of the scapula, although any other 
muscular portion of the body may be selected. The dose 
at first is one-tenth to one-fifth of a milligram, and if no re- 
action occurs, then one milligram and, finally, five to ten 
milligrams at three-day intervals. The patient must be 
afebrile, for a rise in temperature is one of the most impor- 
tant signs of a reaction. 

The reaction is threefold: (a) local; (b) focal; (c) gen- 
eral ; and it occurs in from four to thirty-six hours, the gen- 
eral reaction usually taking place in from four to twelve 
hours. The local reaction is indicated by redness and swell- 
ing at the site of the injection; the focal by signs of in- 
creased activity in the suspected focus of disease in the 
lungs, such as pain, increased cough and expectoration, and 
if rales were previously present, they are more evident. The 
general reaction consists of a rise of temperature from ioo° 
to 102° F. or more; general malaise much like that from an 
attack of influenza, with headache, pain in the joints and 
back, anorexia, sweating, weakness and frequently nausea 
and vomiting. It is generally best to keep the patient in 
bed from twenty-four to forty-eight hours after the injection, 
although this cannot always be realized, and the test can be 
made with ambulatory patients, and they can be instructed 
to take their temperature at home. 



DIAGNOSIS, CONTINUED JJ 

The subcutaneous tuberculin test in the doses indicated 
above is without danger and can be safely employed, and it 
is the most reliable of all the methods of using tuberculin for 
early diagnosis. It is to be remembered that a reaction only 
indicates that there is a tuberculous focus somewhere in the 
body; it does not tell us where it is or whether or not it is 
active and treatment is required. With other evidence, 
however, of active tuberculosis, it renders the diagnosis 
more certain, but does not make it positive. A failure to 
react, after a thorough trial, either gives us a probable assur- 
ance that no tuberculosis exists, or that the disease is so far 
advanced that the reactive forces of the body have lost their 
power. One of Brown's aphorisms is pertinent here; he 
says: 

"No modification of the tuberculin tests as yet devised 
differentiates clearly clinical tuberculosis that demands 
vigorous treatment from non-clinical tuberculosis that re- 
quires only a God-fearing life/' 

The Stages of Tuberculosis 

The following classification, essentially that adopted by 
the National Association, is generally employed in grouping 
the different stages of the disease. 

I. Incipient: Slight infiltration limited to the apex or a 
small part of one lobe. Slight or no constitutional symp- 
toms (particularly including gastritis or intestinal disturb- 
ances or rapid loss of weight). Slight or no elevation of 
temperature or acceleration of pulse at any time during the 
twenty-four hours; especially if at rest. Expectoration, us- 
ually small in amount or absent. Tubercle bacilli may be 
present or absent. No tuberculous complications. 

II. Moderately Advanced: No marked impairment of 
function, either local or constitutional. Localized consoli- 
dation moderate in extent, with little or no evidence of de- 
struction of tissue, or disseminated infiltration. No tubercu- 
lous complications. 

III. Far Advanced: Marked impairment of functions, lo- 
cal and constitutional. Localized consolidation, intense or 



^8 PULMONARY TUBERCULOSIS 

disseminated areas of softening, or serious tuberculous com- 
plications. 

Such a classification is more or less unsatisfactory because 
in practice the extent of the physical signs in many cases 
does not agree with the symptoms of the stage to which the 
signs belong; for example, the physical signs may indicate 
a moderately advanced or a far advanced case, while there 
are only the symptoms of an incipient case. To remedy 
this, Dr. Rathburn of the Otisville Sanatorium, N. Y., has 
suggested the following classification of the physical signs 
and symptoms. 

Physical Signs: 

Stage I. Slight infiltration limited to the apex of one or 
both lungs or a small part of one lobe. No tuberculous 
complications. 

Stage II. Localized consolidation, moderate in extent, 
with little or no evidence of cavity formation, or infiltration 
more than under incipient (Stage I.). No serious tuber- 
culous complications. 

Stage III. Marked consolidation of an entire lobe, or dis- 
seminated area of beginning cavity formation; or serious 
complications. 
Symptoms : 

A. (Slight or none.) Slight or no constitutional symp- 
toms (including particularly gastric or intestinal disturbance 
or rapid loss of weight). Slight or no elevation of tempera- 
ture or acceleration of pulse at any time during the twenty- 
four hours. Expectoration, usually small in amount, or ab- 
sent. Tubercle bacilli may be present or absent. 

B. (Moderate.) No marked impairment of function, 
either local or constitutional. 

C. (Severe.) Marked impairment of function, local and 
constitutional. 

Thus, for example, a patient with physical signs of a far- 
advanced lesion (Stage III), with no marked impairment of 
function, either local or constitutional, would be classified 
III B; or a moderately advanced case as to the physical 
signs (Stage II), with incipient symptoms would be classi- 



DIAGNOSIS, CONTINUED 79 

fied as II A. In this way, one obtains an accurate idea of 
the extent of the lung involvement, and also of the toxsemic 
state of the patient. 

Further Advanced Disease 

When the disease has advanced beyond the early stage, 
the diagnosis, as a rule, is more readily made, — the symp- 
toms are more evident, and the physical signs more definite : 
— toxaemic indications show themselves and rales are gen- 
erally present. 

Moderately Advanced Tuberculosis 

In this stage there is more or less solidification, and, if 
slight, it may be difficult to recognize it, especially if at the 
right apex. The resonance will be impaired and the breath- 
ing will be rough, or broncho-vesicular. The voice sounds, 
also, will be intensified. There will often be some softening, 
indicated by rales of varying size and by the expectoration. 
Some of the unmistakable symptoms of tuberculosis, such as 
cough, weakness, loss of weight, rapid pulse and rise of 
temperature will generally be present. 

More Advanced Tuberculosis 

As softening proceeds, the character of the rales changes : 
they are more numerous, larger and more liquid. With the 
increase of the consolidation, the breath sounds approach 
the bronchial type, and bronchophony is present over the 
diseased area. When a cavity exists, it is not always easy 
to recognize it, and it does not make much difference if it is 
not detected, for the other evidence indicates the state of the 
case. "Practically," says Gee, "the physical diagnosis of 
excavation mostly comes to this : that in progressive phthisis 
a cavity is presumed to be present where the bronchial 
breathing is most intense. " The signs usually relied upon 
for the diagnosis of a cavity are (a) amphoric or cavernous 
respiration; (b) cracked-pot resonance on percussion, and 
dullness; (c) coarse gurgling rales. 

When contraction takes place after excavation, the nor- 
mal expansion of the diseased side is either markedly de- 



SO PULMONARY TUBERCULOSIS 

creased or absent, there is woodeny dullness over the area 
and there may be complete absence of breath sounds; or, 
if the arm is raised, one generally hears cavernous respira- 
tion in the apex of the axilla. The cavity is generally dry 
and rales are absent. With the contraction, the heart is 
more or less displaced; if the contraction is in the upper left 
lobe, the heart may be displaced upwards ; if in the right 
upper lobe, it may be displaced to the right. In the oppo- 
site lung, if not diseased, there is generally compensatory 
hypertrophy, with increased functional activity, indicated 
by rough breathing and prolonged expiration. 

Mode of Advance of Pulmonary Tuberculosis 

From the primary focus which, in the large majority of 
cases, is at the apex, the disease usually extends downward 
along the anterior aspect of the upper lobe. Next, the apex 
of the lower lobe of the same side is usually affected, often 
long before any extensive infiltration or softening has oc- 
curred in the upper lobe, and generally before the opposite 
lung is attacked. The bases are often but little affected and 
may not be at all. The spread of the disease in the opposite 
lung takes place in the same way. Fowler has observed 
that the earlier lesion does not occur at the actual summit 
of the apex, but one to one and one-half inches lower, corre- 
sponding in front with the middle of the clavicle. From this 
part the lesions spread at first chiefly backward, so that the 
signs behind are more evident than those in front. Fowler 
also mentions that a favorite early spot for secondary in- 
fection is the middle of the interlobar septum, correspond- 
ing with a spot in the upper part of the axilla; hence, one 
should always carefully examine this region. 

As the disease progresses, both sides, as a rule, become 
involved, but often not equally so. In the incipient stage 
one rarely finds both apices affected at the same time. 



DIAGNOSIS, CONTINUED 



81 




Fig. 12. Showing the common seat of the earliest tuberculous lesions 

(after Fowler) 

Differential Diagnosis 

(a) Actinomycosis: There are other conditions and dis- 
eases which may be mistaken for tuberculosis, some rare and 
others more common, (a) Actinomycosis is one which may 
first manifest itself in the lungs. The physical signs, how- 
ever, are usually basic while the apices are clear. The oc- 
cupation of the patient which causes him to deal with cereals ; 
the presence of lesions elsewhere in the body; the pain; the 
absence of tubercle bacilli in the sputum or in the pus from 
an abscess, after repeated examinations and the detection 
of the ray-fungus will clear up the diagnosis. It is not a 
common disease, but it occurs, and I have mistaken it for 
tuberculosis. Of course, it may be associated with tuber- 
culosis in the same individual. 

(b) Malignant Disease of the Lungs: This is also rare, and 
can hardly be mistaken. There may be a history of pre-existing 
malignant disease in other parts of the body dyspnoea; 
marked rapid cachexia; severe persistent localized pain; ab- 
sence of tubercle bacilli in the sputum. The physical signs 
are more likely to be found in the middle or base of the lung, 
and do not advance as in pulmonary tuberculosis. We may 
have bloody pleural effusion, but this may occur also in 
tuberculosis. If there is doubt as to the diagnosis, the X-ray 
will be of service. 

(c) Pulmonary Syphilis is of still rarer occurrence, although 
the co-existence of syphilis and tuberculosis is not infre- 
quent. From the physical signs one cannot differentiate 



82 PULMONARY TUBERCULOSIS 

pulmonary syphilis from pulmonary tuberculosis. The 
points which suggest the former disease are (a) more exten- 
sive physical signs than the symptoms would indicate; (b) 
the history of and evidence of syphilis elsewhere in the body ; 
(c) the absence of tubercle bacilli; (d) laryngeal and pharyn- 
geal lesions; (e) the effect of anti-syphilitic treatment. 
When doubt exists a Wasserman test should be made. 

(d) Influenza: This infection often simulates very closely 
pulmonary tuberculosis. The constitutional symptoms and 
physical signs may be quite similar. The physical signs are 
more likely to be found at the base than at the apices of the 
lungs ; still, we may have dullness, rales and modified breath- 
ing at the latter location. The sputum, which is purulent, 
does not contain tubercle bacilli, but does the influenza bacil- 
lus. In influenza the constitutional symptoms may not be 
so severe as the apparent extent and activity of the lung 
process would indicate, nor is the disease generally so 
chronic or progressive. Often a patient gives the history 
of a previous attack of influenza which may have been an 
active outbreak of a latent tuberculous focus, which latter 
again became inactive. 

(e) Malaria: Formerly the mistake was common of treat- 
ing a case of tuberculosis for malaria from error in diag- 
nosis. At the present time, a careful physical examination, 
together with that of the blood and sputum, and, if neces- 
sary, the therapeutic test of Quinine ought to clear up any 
doubt. 

(f) Bronchiectasis: The history, course and physical signs 
differ in this disease from those in pulmonary tuberculosis. 
In bronchiectasis we have the history of a prolonged bron- 
chitis with intermittent expectoration of a profuse, ill-smell- 
ing sputum in which tubercle bacilli are absent. Generally 
there is no pyrexia, and the constitutional symptoms are 
slight. The physical signs are generally at the base and 
suggestive of a cavity. 

(g) Bronchitis: Many a poor consumptive has been de- 
luded by the diagnosis of ''bronchitis" or "bronchial affec- 
tion" because he had a lingering and severe cough, and lost 



DIAGNOSIS, CONTINUED 83 

his golden opportunity for treatment; and yet the differen- 
tial diagnosis is not difficult. In bronchitis the physical 
signs are almost always bilateral and consist mainly of a 
variety of rales, especially bubbling and sibilant, similar on 
both sides, and more often confined to the bases of the lungs ; 
there is no dullness and little if any change in the respiratory 
murmur. The constitutional symptoms are not commen- 
surate with the extent of the disease as indicated by the 
rales; there is no such loss of weight or strength and the in- 
creased temperature does not persist; the sputum shows no 
tubercle bacilli. Nevertheless, one must bear in mind the 
fact that a bronchitis may mask an underlying tuberculous 
lesion and only continued observation and examination of 
the sputum, or an hemoptysis will clear up the doubt. 

(h) Neurasthenia: In this condition the effect has not 
infrequently been taken for the cause. The debility, 
anaemia, loss of flesh, anorexia, digestive disturbances, and 
perhaps cough, — some or all of which may be present in 
the supposed case of neurasthenia, may be due to a tuber- 
culous infection. In the former case, however, there is no 
pyrexia, no tubercle bacilli in the sputum, if there is any 
sputum, and no physical signs discoverable. In every case 
of supposed neurasthenia the possibility of tuberculosis 
should be kept in mind, and a thorough physical examina- 
tion always made. In not a few instances one will have to 
suspend judgment and keep the patient under observation. 
Fortunately in both conditions the treatment is essentially 
the same. 

(i) Asthma: Asthmatic signs may mask a tuberculous 
lesion, and one can only wait for an opportune moment when 
such signs are absent to make a satisfactory examination. 
The history, examination of the sputum, and the general 
symptoms will generally lead one toward a correct diagnosis. 

(j) Pleurisy: Pleurisy is so often secondary to tubercu- 
losis that a careful examination should always be made of 
the lungs to detect a primary tuberculous focus. We may 
find fine rales at the apex, but in case of pleurisy they are 
not lasting. If there is an effusion, and no other evidence 



84 PULMONARY TUBERCULOSIS 

of tuberculosis, animal inoculation may be necessary to de- 
termine the nature of the fluid. 

(k) Cardiac Lesions: The heart should always be ex- 
amined when investigating the condition of the lungs ; other- 
wise one may sometimes be deceived when hemoptysis and 
oedema are present, as in mitral lesions, especially stenosis. 

Other Diseases and Conditions 

Persistent anaemia, diseases of the upper respiratory 
tract, abscess of the lungs, chloresis, dyspepsia with loss of 
weight, a localized suppurative process, hyperthyroidism, 
and, rarely, Hodgkin's disease, present some of the ear- 
marks of pulmonary tuberculosis ; but a careful investigation 
will differentiate them from the latter disease. 

Three aphorisms of Gee may form a fitting close to this 
chapter upon diagnosis : 

(a) " Almost every chronic affection of the apex of the 
lung is tubercular in origin." 

(b) "Therapeutics must begin before physical signs have 
developed ; if you wait for physical signs you wait too long." 

(c) "In a young man an attack of hemoptysis is quite 
sufficient indication for treating him for pulmonary tuber- 
culosis. It is not so in the case of a young woman." 

Illustrative Cases of Differential Diagnosis 

I. Actinomycosis: 

W. J. H. Aged 44 — Expressman, had previously always 
been well and actively engaged in business. Without ap- 
parently known cause he developed severe pain in the right 
middle axillary regions, accompanied by acute symptoms 
and an irregular temperature going as high as 104 F. and 
105 F. on several occasions. The diagnosis of pleurisy, 
and later pneumonia, was made by the attending physician. 
Seen several weeks later, he had a daily rise of temperature 
to 101 and a spasmodic cough with copious muco-purulent 
expectoration, sometimes accompanied with a little blood. 

On physical examination over the upper right front there 
was diminished respiration, and over the middle lobe there 



DIAGNOSIS, CONTINUED 85 

was dullness, bronchial respiration, broncophony and abun- 
dant medium-sized moist rales. Over an area in the middle 
axillary region there was amphoric breathing. 

A diagnosis of abscess of the lung was made and an ex- 
ploratory puncture advised. This was done but without 
result. The sputum was negative to tubercle bacilli but 
contained many elastic fibres, desquimated epithelial cells, 
and a large amount of pus. Cultures from the sputum 
showed a growth consisting principally of streptococci and 
pneumococci. As time went on he improved so much in 
general condition that he went to Florida for the winter, 
where he developed a series of abscesses in the right axillary 
and cervical regions accompanied with great pain. The lo- 
cal physician made the diagnosis of either tuberculous glands 
or Hodgkin's disease. 

On his return from Florida he entered the hospital suffer- 
ing great pain from a series of suppurating abscesses, with a 
spasmodic cough and bloody muco-purulent expectoration. 
While in the hospital the diagnosis of actinomycosis was made 
for the first time, the fungus being found in the discharge 
from the abscesses. He died about a month later. 

Here again comes in the general rule that any pulmonary 
disease not having its origin in the apex is not tuberculosis. 
It was learned, in investigating some possible source of in- 
fection, that the man had been in the habit of chewing straw 
in the stable while his horse was being harnessed. 

II. Bronchitis: 

G. A., aged 32, business. Family history unknown. Past 
history: never ill in his life except an operation for fistula 
six years previously. 

Present illness: is just out of the hospital where he has 
been for 25 days, with fever, cough, and acute symptoms. 
The diagnosis was said to have been pneumonia. Just pre- 
viously to entering the hospital he says he had a slight 
hemoptysis. While in the hospital he lost about nine 
pounds. 

On physical examination, in the left lower back there were 
abundant moist rales ; otherwise the lungs were negative. 



86 PULMONARY TUBERCULOSIS 

According to the man's statement he was told he had pul- 
monary tuberculosis, and application was made for his en- 
trance into the sanatorium. From the fact that the only 
physical signs were in the base of the lungs, and there were 
no other signs or symptoms of active disease, the condition 
was not considered one of pulmonary tuberculosis but rather 
a localized bronchitis. In the course of a few months the 
signs entirely disappeared and the man had been perfectly 
well for the last three years. 

This case again illustrates the general experience that 
when physical signs are only found in the base it is not tuber- 
culosis. 

III. Nezv Growths in the Lungs: 

Mrs. W. G., aged 45, housewife. A well nourished woman 
weighing about 160 lbs.; had always enjoyed good health 
with the exception of a retroperitonial cyst, for which she 
was operated upon ten years previously. Within the last 
year she has had several attacks of bronchitis, each lasting 
about a week. Some four or five months ago fluid was dis- 
covered in the right chest, which was repeatedly aspirated, 
sometimes as often as once a week and as constantly accumu- 
lated. There was a moderate amount of constitutional dis- 
turbance, with some temperature, but practically no cough 
or expectoration. The exudate was negative by the guinea 
pig test, as was the sputum, to tubercle bacilli. The tuber- 
culin test was also negative. 

On physical examination there was marked dullness over 
the whole right lung, with absent or very distant respiration. 
No rales — nothing detected in the heart or other organs. 
The X-ray picture taken many times, both before and after 
aspiration, showed a dense shadow greater or less according 
as the pleural cavity was full or partly free from fluid. The 
patient was seen by a number of physicians, but no definite 
diagnosis was made. Influenza infection, tuberculosis, and 
malignancy were considered the three possibilities. 

After a number of weeks of constant tapping the fluid be- 
came purulent and it was decided to make a permanent open- 
ing by the resection of a rib. At the operation a portion of 



DIAGNOSIS, CONTINUED 87 

tissue was obtained, which on examination showed malig- 
nancy. A fatal issue soon after followed. 

IV. New Growths in the Lungs: 

R. M., aged 70, was a well preserved old man who had al- 
ways been fairly well and active. He had never had any 
serious illness. Six or seven weeks previously he began to 
have a hacking cough which had progressively increased so 
that he was unable to sleep at night, and in consequence was 
losing both weight and strength. There was some dyspnoea. 
There was no rise of temperature. The pulse was 92 and 
the blood pressure 124 Systolic and 75 Diastolic. On exam- 
ination his appearance was that of a well-nourished man in 
fair general condition. There was marked dullness over the 
left front down to about the fourth rib, with bronco-vesic- 
ular respiration and increased voice. Otherwise the exam- 
ination of the lungs was negative. There was no evidence 
of disease in other organs. The X-ray showed a dense mass 
filling the upper half of the left chest, sharply outlined. The 
examination of the sputum was negative to tubercle bacilli 
but showed numerous pus cells. The blood count showed 
17,200 whites, and the blood smear was negative with the 
exception of the leucocytosis. The Wasserman test was 
negative. 

The man grew progressively weaker, developed some tem- 
perature; the cough persisted, and in a month or two he 
died. 

In this case aneurysm was considered a possibility but 
there was no pulsation to be detected, or other evidence. 
Encapsulated fluid was also considered, but the clinical his- 
tory and physical signs did not lend themselves to this diag- 
nosis. Tuberculosis was ruled out, from the absence of 
tubercle bacilli and other characteristic symptoms. The 
diagnosis of a primary growth in the lungs would appear, 
therefore, from all the evidence, to be well established. The 
one outstanding symptom in this case was the constant and 
harassing cough, undoubtedly caused by pressure. 

V. Bronchiectasis: 

F. K., aged 42, rag merchant. Family history: his father 
died of some pulmonary disease, and his mother of cancer. 



88 PULMONARY TUBERCULOSIS 

Previous history: Always well with the exception of 
pneumonia 24 years ago and again 4 years ago. Two 
months previous to his present visit he had some acute pul- 
monary- affection, indefinite in character, as far as any ac- 
curate description could be obtained from him. Since that 
time he has been suffering from severe paroxysms of cough- 
ing, both night and day, with profuse and very ill-smelling 
sputum, accompanied from time to time by slight hemor- 
rhage. 

Present condition: a fairly well-nourished man, weighing 
141 lbs., with a good appetite, although the intolerable odor 
and taste of the sputum caused more or less nausea and 
vomiting. 

Upon physical examination there was marked dullness and 
distant respiration below the angle of the left scapula. 
Otherwise the lungs were negative. The sputum showed 
no tubercle bacilli but a large amount of pus and a few or- 
ganisms of the strepto-pneumococcic type. On standing, 
the sputum showed the three characteristic layers observed 
in fetid bronchitis. 

The X-ray showed three bronchiectatic cavities with fluid 
levels, the cavities varying in size from y 2 to 1^2 inches. 
The fingers were slightly clubbed, as is not unusual in such 
cases. 

The diagnosis of bronchiectasis was made, from the char- 
acter of the sputum and the absence of tubercle bacilli, the 
location of the physical signs, the paroxysmal cough, and 
the fact that the disease had made so little impression upon 
the general health. The X-ray findings corroborated this 
diagnosis. 

Four possible methods of treatment were considered: 
autogonous vaccine, pneumothorax, irrigation by means of 
bronchoscopy, and pneumectomy. Irrigation was decided 
upon. 

VI. Bronchiectasis: 

Mrs. L. B., aged 40, was referred as a case of pulmonary 
tuberculosis, with '"'a cavity at the left apex." She was a 
fairly well-nourished woman, weighing about 190 lbs. and 



DIAGNOSIS, CONTINUED 89 

appeared to be in average good health. She gave the his- 
tory of having suffered for the past 17 years from a paroxys- 
mal cough accompanied by an ill-smelling expectoration. 
The onset of this 17 year cough was referred to a date short- 
ly after the birth of a child. She described the cough as 
intermittent and always accompanied by quite profuse fetid 
expectoration. Whenever she stooped down or leaned over, 
there was a gush of sputum which was sometimes blood- 
streaked. There was more or less dyspnoea on exertion. 

The physical examination showed marked dullness 
throughout the left lung, with bronchial and broncho-vesic- 
ular respiration and a variety of moist rales. At the apex 
of the lung there was evidence of a cavity. The sputum 
several times examined was negative. The whole of the 
left lung was involved and from the physical signs alone one 
would make the diagnosis of advanced pulmonary tubercu- 
losis, which was the diagnosis of the referring physician. 
The case was, however, one of bronchiectasis of long stand- 
ing, with extensive disorganization of the lung and the diag- 
nosis is established by the absence of tubercle bacilli in the 
sputum, the paroxysmal cough and fetid expectoration and 
the general well-being of the patient. If pulmonary tuber- 
culosis had existed for 17 years, and the destructive process 
had become so extensive as in this case, the woman would 
not have exhibited the appearance of ordinary good health 
which she did, or indeed have been alive. 

This case teaches that when on repeated examination tu- 
bercle bacilli are absent, one must look for some other con- 
dition to account for the physical findings than tuberculosis. 

The following Diagnostic Standards of the National 
Tuberculosis Association prepared by the Diagnostic Stand- 
ard Committees of the "Framingham Community Health 
and Tuberculosis Demonstration" are a concise and excel- 
lent statement of early diagnosis. 



9<D PULMONARY TUBERCULOSIS 

THE DIAGNOSIS OF PULMONARY TUBERCU- 
LOSIS IN ADULTS WITH NEGATIVE 
SPUTUM 

Definitions — Statements 
History 

1. History and Exposure: An occasional case of tubercu- 
losis in the patient's uncles, aunts, cousins, etc., should not 
be considered of importance, unless there has been intimate 
exposure and personal contact with such a case. It is an 
important fact when the patient's immediate relatives such 
as brothers, sisters, father, mother or grandparents have been 
tuberculous, and especially so, when there has been pro- 
longed and intimate contact. 

Childhood exposure is of the greatest importance. Mod- 
erate exposure among normal, healthy adults of cleanly 
habits is of less importance. Of course, prolonged contact, 
with unhygienic habits or surroundings, may be a danger- 
ous factor at any age. The question of occupational haz- 
ards of this type should be thoroughly investigated. 

2. Loss of Weight: By "loss of weight" should be under- 
stood an unexplained loss of at least 5 per cent, below nor- 
mal limits for that particular individual within four months 
time. 

3. Loss of Strength: By "loss of strength" in its patho- 
logical sense is meant undue fatigue and a lack of staying 
power which are unusual for the individual patient and which 
cannot be satisfactorily explained. 

4. Cough: There is no cough characteristic of tubercu- 
losis. Every cough that persists for six weeks or over re- 
quires investigation. Tuberculosis may exist without any 
cough whatsoever. 

5. Hemorrhage : Any amount of expectorated blood, with 
or without sputum, may mean that tuberculosis is present 
and requires careful and thorough medical investigation as 
to its source. Blood streaks, blood spots, etc., may or may 
not mean tuberculosis. On the other hand a hemorrhage 
of one or two teaspoonfuls is presumptive evidence of the 
disease. 



DIAGNOSIS, CONTINUED 91 

Examination 

1. Fever: An occasional temperature of 99 should not be 
considered " fever." A temperature which persistently runs 
over 99.4 when taken at least four times a day over a period 
of one week (by mouth five minutes) should be considered 
of significance and to constitute " fever." 

2. Examination of Pulse: Where the average normal 
pulse of the patient is already known, an elevation of 15 
beats per minute when the pulse is taken quietly at home 
during various periods of the day should be considered 
abnormal. In cases where the average pulse is not known, 
and of course this constitutes the majority of cases, one 
should consider an average pulse of 85 or over in men and 
90 or over in women to be abnormal. The combination of 
a subnormal temperature and an elevated pulse as defined 
here should be considered of great importance. 

3. Hoarseness: Any hoarseness or a persistent "huski- 
ness" requires investigation. 

4. Sputum: The presence of sputum is not necessary for 
a positive diagnosis. The constant raising of sputum, with 

'or without cough, requires investigation. Absence of bacilli 
in the sputum after one or several laboratory examinations 
is not necessarily proof against the presence of active tuber- 
culosis. 

Minimum Standards 

On a basis of these definitions the following minimum 
standards in the diagnosis of pulmonary tuberculosis have 
been formulated: 

1. When constitutional signs and symptoms and definite 
past history are absent, or nearly so, there should be de- 
manded definite signs in the lungs, including persistent rales 
at one or both apices. By "persistent" it is meant that the 
rales must be present after cough at two or more examina- 
tions, the patient having been under observation at least one 
month. 

2. In the presence of constitutional signs and symptoms, 



9-2 PULMONARY TUBERCULOSIS 

such as loss of weight and strength, etc., as defined above, 
there should be demanded some abnormality in the lungs, 
but not necessarily rales. X-ray evidence of apical infiltra- 
tion may be of importance. 

3. Usually a process at the apices should be considered 
tuberculous and a process at the base to be non-tuberculous 
until the contrary is proved, excepting when a clear history 
of pleurisy is present. 

4. A hemorrhage as defined above is evidence of active 
pulmonary tuberculosis until the contrary is proved. 

5. One should consider a typical pleurisy with effusion 
as presumptive evidence of tuberculosis. 

6. Pain in chest and shoulders, night sweats, digestive 
disorders, etc., may be present and should be investigated. 
Fistula in ano should be considered as a tuberculous mani- 
festation, requiring careful examination of the lungs for 
traces of the disease. 

7. In every doubtful case one should demand that the 
patient be kept under observation with record of pulse, tem- 
perature, weight, etc., for at least one month, with repeated 
sputum examinations, before a definite diagnosis is made. 



CHAPTER VI 
The Examination of Soldiers for Tuberculosis 

When the United States was preparing her army for the 
great war, it was decided that every recruit should receive a spe- 
cial examination by experts for tuberculosis. This enor- 
mous task, never before undertaken on such a gigantic scale, 
was successfully conducted and active tuberculosis was dis- 
covered in less than one^per cent, of the men examined. Al- 
though the war is now happily ended, yet the plan and 
methods* pursued will be of interest and profit, and many of 
them can be adopted in civil life such, for example, as the 
examination of employees in large manufacturing establish- 
ments or any large body of men. 

As there is but little time to obtain any extended history 
in the rapid examination of large bodies of men (recruits) 
the principal reliance must be upon physical signs, the exam- 
ination of the sputum in suspected cases, when it can be ob- 
tained, and occasionally, to aid in the diagnosis, the radio- 
graph. 

In the physical examination we have inspection, percussion 
and auscultation. 

Inspection: 

The inspection of the chest is of great importance; one must 
look for various developmental defects of the thorax and if 
found associated with an apparent delicate constitution may 
be a sufficient cause of rejection even if no definite disease 
is discovered. One also observes the supra and infra-clavic- 
ular spaces, and note any undue depression in these regions 
as well as deficient respiratory movement either at one apex 
or both. Enlarged lymphatic glands and scars of any kind 

* From the manual prepared for examiners by Col. G. E. Bushnell, 
U. S. A. 

93 



94 PULMONARY TUBERCULOSIS 

are also to be looked for. All this can be done at a glance 
while the rest of the examination is going on. 

Percussion : 

In percussion one begins at the lower portion of the chest, 
where he is most likely to obtain the normal note of reson- 
ance, and goes upwards, noting the differences, if any, in the 
percussion sound in different areas of the same side and in 
the same area in the two sides. But a few moments, how- 
ever, may be spent upon percussion, for auscultation is far 
more important. 

Auscultation: 

The subject is asked to breathe more rapidly and deeply 
than normally, avoiding noisy respiration, and with the re- 
laxation of the shoulder muscles as much as possible. 
Standing or sitting in front of the subject, who, of course, 
is stripped to the waist, one examines with the stethoscope 
the front and back of the chest and the axillary region. The 
especial signs to be looked for are, first: — The character of 
the respiration; is it rough, diminished, or broncho-vesicular, 
or is the expiration prolonged, and is it jerky? 

Second: — Rales (fine, more or less moist ones), particu- 
larly at the apex, for rales at the base do not in the great 
majority of cases mean tuberculosis — rales may be detected 
in deep inspiration or only upon coughing, and then only 
upon coughing at the end of deep expiration. When rales 
are discovered at an apex and are persistent and if there is 
no evidence of an acute infection like influenza or bronchitis 
it is sufficient cause for rejection. When the evidence is 
not clear from the physical examination the case is deferred 
and subsequently re-examined by a board of three physicians 
and if they agree upon a verdict the subject is either retained 
or recommended for discharge. It will occasionally be 
found that a soldier will present the appearance of perfect 
health, be well-developed and muscular and yet have per- 
sistent rales at one or the other apex. Such a case, if there 
is no evidence of an acute infection, should be rejected, for 



THE EXAMINATION OF SOLDIERS FOR TUBERCULOSIS 95 

undoubtedly under the strenuous military life active symp- 
toms will later appear and a break-down follow. 

Severe Pleural Adhesions: 

There is also a class which should be rejected if the con- 
dition can with certainty be detected and that is severe 
pleural adhesions which bind the pulmonary tissue firmly to 
the thoracic wall. Such a condition is indicated by dimin- 
ished local movement and respiration and perhaps more or 
less dullness. 

Topical Variations of Normal Sounds: 

The following topical variations of normal sounds are 
given by Bushnell * and it is well to bear them in mind: 

(i) Harsh breathing, slightly prolonged expiration over 
right apex posteriorly, without other signs, is not cause for 
rejection (proximity of bronchus). The same signs anter- 
iorly over the right apex, if slight, are not necessarily path- 
ological. 

(2) The same signs in the second interspace right anter- 
iorly close to sternum are not cause for rejection (proximity 
of right main bronchus). If these signs are found outward 
and downward from this point they indicate a lesion. 

(3) Increased vocal resonance and slightly harsh breath- 
ing immediately below center of left clavicle are occasionally 
found. They do not indicate a lesion in the absence of other 
signs. 

(4) Fine crepitations over sternum or heard when the 
stethoscope touches edge of that bone are not pathological. 

(5) Clicks heard during strong breathing or after cough 
in the vicinity of the costo-sternal articulations (below the 
first) in the absence of other signs are not indicative of a 
lesion. 

(6) Sounds resembling rales at base of lung especially in 
right axilla are not pathological if strictly limited to the base 
and to inspiration and not accompanied by other signs. 

(7) The same is true of sound resembling rales over the 
lingula (Heart Apex) heard on cough. 

* " The Diagnosis of Tuberculosis in the Military Service," Bushnell ; " The 
American Review of Tuberculosis," Vol. 1, No. VI, 1917. 



96 PULMONARY TUBERCULOSIS 

(8) Prolonged expiration in left base posteriorly limited 
to this region is not abnormal. 

(9) Slightly prolonged expiration at about the angle of the 
scapula, disappearing a short distance above this point, is 
not a sign of a lesion, if alike on both sides (transmission 
from normal bronchi) and not accompanied by other signs. 

The following instructions for suggestive physical exam- 
ination of the chest were given to medical officers for their 
guidance in examining soldiers : 

I. The subject should be stripped to the waist and scru- 
tinized for various developmental defects of the thorax, and 
if found associated with an apparent delicate condition may 
constitute a cause for rejection or discharge even if no defi- 
nite disease is discovered. All that is absolutely necessary 
is to determine the presence of a tuberculous lesion of suffi- 
cient activity to constitute a cause for rejection or discharge. 
This can be done in well marked cases of active tuberculosis 
in a few moments. To demonstrate the absence of disease 
in suspicious cases naturally requires a longer time. 

Auscultation: 

The subject is instructed to breathe more rapidly and 
deeply than normally, yet avoiding noisy respiration and re- 
laxation of the shoulder muscles as much as possible. The 
examiner, standing in front of the subject, applies the stetho- 
scope to the lower axillary region, going upward anteriorly, 
comparing points on both sides. Xote carefully any change 
in breathing sounds from the level of the third rib upward. 

Examination of Back: 

Secure the breath sounds right base, proceeding upward, 
comparing symmetrical points on either side. 

Physical Signs: 

Look especially for: 

(1) Harshness and jerky inspiration. 

(2) Prolonged expiration. 

(3) Fine crackling rales. 

(4) Feeble breath sounds. 



THE EXAMINATION OF SOLDIERS FOR TUBERCULOSIS 97 

(5) The presence of any type of rale is cause for a de- 

ferred examination. 

(6) Search for enlarged lymphatic glands. 

(a) The question of activity is determined by the presence 
of typical rales. If disseminated rales are present the exam- 
iner needs to go no further to recommend rejection, dis- 
charge or deferred examination. 

(b) Deep expiration and cough will be necessary to elicit 
the indeterminate rales. 

(c) Indeterminate rales in abundance are easily heard and 
are usually cause for rejection, discharge or deferred, exam- 
ination. 

(d) Severe pleural adhesions which bind the lung tissue 
firmly to the thoracic wall is cause for rejection or discharge. 

It will be seen from the above that the object of this exam- 
ination of recruits was the exclusion of manifest tuberculosis 
from the Army. And the test and "only trustworthy sign 
of activity of apical tuberculosis was the presence cf per- 
sistent moist rales." On the other hand "a definitely demon- 
strated tuberculous lesion of more than insignificant size 
below the apex" was considered cause for rejection "whether 
such lesion was active or inactive." 

The following "simplified rules for tuberculosis examina- 
tions" * by Major Stoll, late of the Medical Reserve Corps, 
U. S. A., were arranged and employed by him in instructing 
medical officers in tuberculosis examination, and are equally 
excellent for a guide in civil practice. 



* Journal of the American Medical Association, March 2, 1918. 



For percussion one should < 



98 PULMONARY TUBERCULOSIS 



ESSENTIAL POINTS 

C 1. Inspection. 
Always compare corresponding areas in^ 2. Percussion. 

L 3. Auscultation. 

f 1. Sit erect. 

For inspection, subject must < 2. Relax shoulder muscles. 

[. 3. Face the light. 

f 1. Retraction (apical and over the 

One should look for \ ^. ^)', 

2. Diminished expansion. 

[ 3. Lagging. 

f 1. An old process. 

Signifying respectively A 2. An extensive process or adhesions. 

L3. Active disease. 

1. Exert very firm pressure with 
finger placed parallel with the 
ribs. 

2. Employ a very light uniform 
stroke. 

^3. Percuss from below upward. 

f 1. Breathes very quietly (mouth 
To study the breath sounds, the subject^ ^ s^tiymore deeply. 

^ 3. Slightly more rapidly. 

f 1. Note character of inspiration. 

Be sure to < 2. Length and pitch of expiration. 

L 3. Study of the whispered voice. 

f 1. Tactile fremitus is increased. 
Remember that normally at the rightl 2. Percussion note is less resonant. 

apex J 3. Expiration is somewhat prolonged 

(, and raised in pitch. 

f 1. Expire forcibly. 
Activity is indicated by rales bestj 2. Cough. 

elicited thus : . . . I 3. Inspire (moderately). (Save time 

L by illustrating method.) 

Heard immediately after the cough 
at the beginning of inspiration. 

Usually persist through the whole 
of inspiration. 

With less active lesions, are heard 
only in the first part of in- 
spiration ; sometimes only dur- 
ing the cough. 



The characteristic rales are subcrep- 

itant 

or fine moist 



f 1. In showers. 
Of especial significance are rales that-j 2. Localized, 
are L 3- Persistent. 



They should be sought for with par- 
ticular diligence in the " 



1. Supraspinous fossae. 

2. Supraclavicular space (a) inner 

(b) middle, (c) outer por- 
tions. 

3. First interspace near sternum. 



THE EXAMINATION OF SOLDIERS FOR TUBERCULOSIS 



99 



Do not mistake for the rales of tuber- 
culosis 



Do not consider tuberculosis the fine 
rales ("marginal sounds"), heard 
over the lower lobes, especially in 
the anterior axillary line 



Remember that. 



To minimize mistakes, 



1. The inconstant apical rales at the 

end of forced inspiration. 

2. Sternoclavical crackles. (Hold 

breath, rotate shoulder.) 
^3. Sternal and muscle sounds. 

i. They are crepitant. 
2. Begin in the middle of inspiration 
and attain their maximum at 
the end. 
L. 3. Dissipated by deep breathing. 

i. Lesions of apexes are usually 
tuberculous. 

2. Lesions of base alone are usually 

not. 

3. The most common cause of 

bronchovesicular breathing is 
noisy nasal respiration. 

Re-examinations. 

Sputum and roentgen-ray exam- 
inations. 
L3. Temperature and pulse records. 



{» 



CHAPTER VII 
PROGNOSIS 

" There is a history in all men's lives," 

" Figuring the nature of the times deceas'd." 

" To which observ'd a man may prophesy," 

" With a near aim, of the main chance of things " 

" As yet to come to life, which in the seeds" 

" And weak beginnings lie entreasured." 

Henry IV, Part II, Act III, Sc. I. 

When a definite diagnosis of pulmonary tuberculosis has 
been made, the patient naturally wants to know what are 
his chances of recovery, and although it is obviously impos- 
sible to give any positive opinion without the observation of 
the patient for a period of time, while he is under treatment, 
and gauge the response of his defensive forces ; yet there are 
certain indications which the history and examination may 
have revealed, which will aid us in forming some estimate of 
the future course and result of the disease. 

Definition of "Cure" 

What is generally meant by a "cure" is not a "restitutio 
in integrum, " as though the disease had never existed, but 
a permanent arrest of the infection and its local process, so 
that the individual is restored to his former life of activity; 
he is clinically, or, as some choose to call it, "economically" 
well. What is the probability of obtaining this desired re- 
sult is the question to be answered. 

In studying the individual case in reference to the prog- 
nosis, all the factors involved, past and present, should be 
considered, and no one factor should be regarded as of para- 
mount importance ; physical signs alone should not constitute 
the basis of the prognosis, for the symptoms are of equal if 
not greater importance. "The nature of the symptoms," 

IOO 



PROGNOSIS IOI 

says Lindsay, "probably gives us the most trustworthy of all 
prognostic indications." To go beyond the present indica- 
tions, the most reliable guide, as has been referred to above, 
is the reaction of the patient under treatment. After a suffi- 
ciently extended trial, if there is no response, the patient is 
doomed. 

I once remarked to Walther, the head of a well-known 
sanatorium in Germany, that I supposed he only received 
early cases. "I take all kinds of cases," he replied. "I never 
can tell whether they will recover or not." There are early 
cases, so far as the physical signs are concerned, who de- 
velop no resistance and the disease pursues a steady down- 
ward course, do what we will; and, on the contrary, there 
are other more-advanced cases, who show remarkable re- 
sponse to treatment and eventually arrive at an enduring 
arrest. But few cases, then, should be pronounced abso- 
lutely hopeless. 

General Propositions 

The general propositions to be kept in view in giving a 
prognosis are well stated by Lindsay. * 

(i) "Whether there is a reasonable hope of complete re- 
covery." 

(2) "Whether the case is, upon the whole, favorable, a 
good rally probable and treatment likely to repay its cost 
in time and money." 

(3) "Whether the case is, upon the whole, unfavorable, 
and admitting only a moderate degree of improvement." 

(4) "Whether the case is definitely unfavorable and ad- 
mitting only a slight degree of palliation." 

(5) "Whether the case is obviously hopeless and sys- 
tematic treatment useless." 

It is self-evident and proved by experience that the earlier 
the disease is diagnosed and treatment instituted, the better 
the prognosis, and, on the contrary, the later the disease 
comes under treatment the more unfavorable the prognosis, 
but there are not a few exceptions. 

1 " Diseases of the Lungs." N. Y. 1904. 



102 PULMONARY TUBERCULOSIS 

Especial Indications 

(a) Character of the onset: 

The more acute the onset, as it were, an advanced case 
from the beginning, the less favorable is the prognosis, while 
an insidious onset is of no definite prognostic significance. 

(b) The rate of progress in relation to the duration of the 
symptoms : 

If the disease has existed but a short time and yet there 
is evidence of rapid extension and destruction of lung tissue, 
or both lungs are involved at an early period, the prognosis 
is unfavorable. 

(c) The character of the constitutional symptoms: 

If these are marked, such as persistent high temperature, 
rapid pulse (either with or without fever), progressive loss 
of weight and strength, anorexia and digestive disturbances, 
the prognosis is unfavorable, while, on the contrary, absence 
of pyrexia, a gain in weight, diminished cough and expec- 
toration are favorable signs. 

(d) Increase of moisture in the diseased portion, as indi- 
cated by the increase and size of moist rales is unfavorable, 
even if there is general improvement. Hemoptysis in the 
course of the disease, if unaccompanied with fever, dyspnoea, 
tachycardia or other acute symptoms, is not of serious 
moment. 

(e) Any serious complication, either tuberculous or non- 
tuberculous, such as diabetes, albuminuria, syphilis, laryn- 
geal tuberculosis, chronic diarrhoea, peritoneal or intestinal 
tuberculosis, render the prognosis more unfavorable. Preg- 
nancy has generally been considered an unfavorable compli- 
cation, but it is not invariably so; much depends upon the 
stage and activity of the disease at the commencement of 
the pregnancy. Occasionally actual improvement has taken 
place as a result of the condition. As a rule, however, preg- 
nancy, in an active state of the disease, must be regarded as 
of unfavorable prognostic significance. Fistula-in-ano does 
not materially affect the prognosis, nor does an intercurrent 
pleurisy; if there is effusion, whether removed by absorption 



PROGNOSIS 103 

or aspiration, the favorable course of the disease may go 
on thereafter uninterruptedly. Various acute diseases oc- 
curring shortly before the advent of the tuberculosis render 
the prognosis rather more unfavorable, such as influenza, 
pneumonia, typhoid fever, bronchitis, and whooping cough 
and measles in children. They lower the resistance of the 
patient to the new tuberculous infection. When the con- 
stitutional symptoms are marked and out of proportion to 
the physical signs, indicating the virulence of the infection 
and ascendency of the toxaemia, the outlook is unfavorable 
unless resistance can be promptly developed by treatment; 
and when the physical signs and symptoms are at variance 
the symptoms are a safer prognosis guide than the physical 
signs. 

Bearing of the Previous Life and Habits upon the Prognosis 

If the patient has lived a regular life under good hygienic 
conditions as to food, fresh air and rest, and yet develops 
pulmonary tuberculosis, the prognosis is less favorable in 
his case than that of one who has lived and worked under 
unwholesome hygienic conditions and been subjected to 
deprivations of one kind or another, for the treatment in the 
latter case is a more radical change in his mode of life than 
in the former case and may be expected to elicit a more 
ready and marked response. In the one case the unhygienic 
conditions of living may justly be regarded as the exciting 
cause of the tuberculosis, while in the other we can only 
refer the development of the disease to an inherent lack of 
resistance. 

Family Predisposition 

How much importance should be attributed to the family 
history in estimating the prognosis it is difficult to say; in 
general, a rather more guarded prognosis should be given 
in the case of a patient with a tuberculous family history. 
That families vary in resistance to infection is a familiar 
fact; but that a specific lack of resistance to the tubercle 
bacillus exists in those of a tuberculous family history is 



104 PULMONARY TUBERCULOSIS 

questionable ; a weak constitution, however, may be inherited 
which renders one more susceptible to any infection. Tu- 
berculosis in one's immediate family may indicate a family 
predisposition to the diseases or merely greater opportuni- 
ties for contracting it. 

The Temperament 

Again, the temperament of the patient has a bearing upon 
the prognosis : We have the nervous type, represented by 
a person who is easily fatigued, has an indifferent appetite 
and poor digestion, and who sleeps but poorly; or the lym- 
phatic type, which feebly responds to treatment, and in 
which loss of strength and a general depressed condition are 
the prominent symptoms. The physical signs may be slight 
and the symptoms subacute, and the patient may look pretty 
well ; but with this type, as with the preceding one, the prog- 
nosis must be guarded. On the other hand, there is the 
thin, sinewy type, with much endurance, a good appetite and 
digestion and a strong heart, — a type in which the local lesion 
is limited and tends to fibrosis rather than softening; and 
the hemorrhagic type in which small recurring hemorrhages 
occur, without effect upon the general condition, and in 
which the physical signs are insignificant. Both of these 
types offer a very fair chance of recovery. 

Character and Intelligence of the Patient 

A patient of determination and intelligence, who thorough- 
ly grasps the situation, and is resolved to faithfully and per- 
sistently carry out the treatment and co-operate with his 
physician, obviously offers a better prognosis than one ac- 
customed to self-indulgence, who has always had his own 
way, and who will not submit to the rigorous training in- 
volved in the treatment. As some one has facetiously, but 
with a good deal of truth, said : "It depends more upon what 
is above the collar than what is below, whether or not one 
recovers." Ignorance and an inability to comprehend the 
situation and intelligently follow the indications render the 



PROGNOSIS I05 

prognosis far less favorable: "It is impossible to cure a 
fool." 

Age and Sex 

As a rule, the very young and the old do badly, while the 
prognosis is best in early adult life. As to sex, the prog- 
nosis seems to be rather more favorable in the male sex; 
but this may be due merely to the different habits and mode 
of life of the two sexes. 

Various Other Conditions 

The occupation; social status; financial ability to obtain 
the proper treatment; the habits, particularly as to the use 
of alcohol, or other excesses, are all obvious points to be 
considered in the prognosis. 

Food 

A most vital indication with regard to the prognosis, 
while the patient is under treatment, is the matter of the 
ingestion and digestion of food. If he can eat and digest the 
requisite amount of food and be nourished by it, it is an ex- 
ceedingly favorable prognostic omen. If, as Napoleon said, 
"an army marches upon its belly,' , so a consumptive fights 
his disease with his stomach. "A consumptive who cannot 
eat is doomed." 

Final Summary 

In estimating the probable outcome in any individual 
case, the final judgment must be based upon the resistance 
of the patient to the bacilli and their toxins. The result 
depends upon the issue of the conflict between these two 
opposing forces, and only after a period of observation of 
the contest can we form a reasonable opinion as to the ulti- 
mate result. 

Let us marshal the two opposing forces. The activity 
of the infecting forces, which means victory for them, is indi- 
cated by the following symptoms and signs: 



106 PULMONARY TUBERCULOSIS 

Rapid and low tensic n : n Ise. 

: Fever. 
(c) Steady and rapid loss of weight. 
: Anorexia and digestive disturbances. 

(e) Loss ::' strength. 

: Marked dyspnoea. 
And with reference to the local process, evident extension 
and softening, with numerous tubercle bacilli and a variety 
of rales. 

On the side of the resistance, as indicating victory, we 
have : 

(a) No fever. 

(b) Quiet pulse and nervous system. 

(c ) Weight not diminished or uteres. sir.:;. 

(d) Good appetite and digestion. 

(e) Strength not materially lessened. 

And the local process limited and not advancing. 

It is well again to repeat that the physical signs may be 
very slight and yet the constitutional symptoms marked, in- 
dicating that the toxoemia has overcome the resistance : or, 
on the other hand, we may have extensive physical signs 
with few or no constitutional symptoms, indicating that at 
least an equilibrium or stalemate, more or less permanent, 
exists between the opposing forces. 

Scheme of Results 

The scheme of results adopted by the National Associa- 
tion for the Study and Prevention of Tuberculosis and the 
American Sanatorium Association in 19:3 is as follows: 

I. Apparently cured: All constitutional symptoms and 
expectoration with bacilli absent for a period of two years 
under ordinary conditions of life. 

II. Arrested: All constitutional symptoms and expector- 
ation with bacilli absent for a period of six months, the phys- 
ical signs to be those of a healed lesion. 

III. Apparently arrested: Same as above, except for a 
period of three months. 

IV. Quiescent: Absence of all constitutional symptoms; 



PROGNOSIS IO7 

expectoration with bacilli may or may not be present; phys- 
ical signs stationary or retrogressive; the foregoing condition 
to have existed at least two months. 

V. Improved: Constitutional symptoms lessened or en- 
tirely absent; physical signs improved or unchanged; cough 
and expectoration with bacilli usually present. 

VI. Unimproved: All essential symptoms and signs un- 
abated or increased. 

The following prognostic theses of Dr. Lawrason Brown * 
of Saranac are very suggestive : 

Prognostic Theses 

1. "The uncertainties of prognosis decrease rapidly after 
the first year of disease but are ever present. " 

2. "Whoever suffers relapse from unavoidable adverse 
conditions does better than he who relapses without dis- 
coverable cause." 

3. "Lack of self-restraint is no great bar to recovery be- 
fore the fifteenth year, but lack of self-restraint after this 
age often spells death." 

4. The mentality and characteristics of the patient's fam- 
ily, their ability and willingness to help in his recovery by 
self-sacrifice over long periods of time, are most important. 
Therefore recovery in the midst of the family is the most 
favorable recovery. 

5. He who has worked indoors does better, ceteris paribus, 
than he who had always seen the light of the sun in God's 
fresh air. 

6. Recovery in a climate in which the patient is to live, 
especially if accomplished at home, bespeaks greater longev- 
ity than immediate change of climate on arrest of disease. 
Climate may be only a minor factor in this effect. 

7. An acute onset with extensive physical signs or with 
severe and protracted symptoms points to a prolonged ill- 
ness or an early fatal termination. 

8. Complications, particularly when tuberculous, are al- 
ways to be dreaded. 

* The American Review of Tuberculosis, Vol. I, No. 4, June, 1917. 



108 PULMONARY TUBERCULOSIS 

9. The consumption of the body, with or without fever, 
indicates that assimilation is failing, and when steady and 
continuous is a priori evidence of poisoning of the body 
cells. 

10. The continuous gain of weight on an ordinary diet is 
the best indication of favorable progress but can occur with 
advancing disease. 

11. Assimilation depends primarily upon ingestion and 
"poor eaters" with strong antipathies to milk, eggs and 
meat do badly. 

12. Digestion is the keystone of the prognostic arch. 

13. Fever is the best sign of progressive disease and its 
chances of disappearance are inversely proportional to the 
length of time it has persisted. 

14. Persistent high temperature under appropriate treat- 
ment, with slight physical signs, is grave. 

15. Frequent, recurring febrile attacks indicate advancing 
disease. 

16. The pulse rate, together with the temperature and 
weight, forms the prognostic triad. 

17. A pulse constantly over one hundred, when the patient 
is at rest in bed, is of bad omen, when not due to digestive 
disturbances. 

18. The patient's mental attitude is of nearly equal im- 
portance to his physical reaction to his disease. 

19. Dyspnoea may be the only pronounced symptom of 
acute miliary tuberculosis of the lungs. 

20. Uncontrollable excessive cough is the worst form of 
over-exercise and favors a quick deterioration of the bodily 
resistance. 

21. Physical signs tell by inference what has happened in 
the lungs, symptoms what is happening. The general con- 
dition is more important than the physical signs or the his- 
tory. 

22. The most certain thing about the physical signs of 
"activity" or "softening" is their uncertainty. 

23. Extent of disease marks the time element; intensity 
the acuteness. 



PROGNOSIS IO9 

24. Granting the diagnosis, slight deviations in breathing 
or percussion are the most favorable physical signs. 

25. The condition of the opposite side in advanced disease 
affects seriously the prognosis. 

26. Increase of physical signs with marked lessening of 
localizing and general symptoms and gain in weight does 
not necessarily indicate an advance of disease. 

27. Improvement or even arrest may occur without change 
in physical signs. 

28. The greater the quantity, and possibly the greater the 
fluidity of sputum, when persistent, the less favorable the 
prognosis. 

29. Tubercle bacilli in the sputum indicate bronchial ulcer- 
ation, and the larger the number possibly the greater or 
more acute the ulceration, but enormous masses may occur 
in favorable cases. 

30. Duration of treatment of less than three months is of 
little permanent help, while three or four years of treatment 
may complete an arrest. 



CHAPTER VIII 
TREATMENT 

" I cannot help believing that medical curative treatment will resolve itself 
in great measure into modifications of the food swallowed, and breathed, and 
of the natural stimuli and that less will be expected from specifics and 
noxious disturbing agents." 

O. W. Holmes, 1861. 

Cases Requiring No Treatment 

In the first place, one should bear in mind that pulmonary- 
tuberculosis which has been diagnosed by the physical signs 
alone, and is without symptoms, requires no treatment. 
Symptoms are the indication of active disease, and for active 
treatment. This point needs to be emphasized, for it has 
happened that individuals have been condemned to unneces- 
sary treatment, their accustomed life disarranged, and their 
domestic economy upset, solely upon the ground that physi- 
cal signs were discovered. 

The Patient Should Be Told His Condition 

At the outset the patient should be told, in a kindly and 
tactful way, his condition, and the hopeful outlook in his 
case, supposing it is a curable one, if he conscientiously fol- 
lows out the treatment and co-operates with his physician. 
It should be impressed upon him that disaster is likely to 
follow if he neglects or defers the proper treatment. The 
same should, likewise, be said to his family or friends. The 
treatment is then explained in detail, and the plan for the 
individual case arranged, whether the treatment is taken in 
or out of a sanatorium. 

Principles of the Treatment 

Like the snakes in Ireland, there is no remedy for pul- 
monary tuberculosis in the sense of a specific medicine or 

no 



TREATMENT III 

form of treatment directly applied to the exciting cause, — 
the tubercle bacillus. Innumerable supposed specifics have 
been proposed and tested, but all have been found wanting. 
The only treatment which has successfully stood the test of 
time and experience is the indirect one of developing and 
maintaining the resistance of the individual to the toxaemia 
of the infection. We name it the "hygienic-dietetic" or 
"open-air" treatment. In brief, it consists (a) in breathing 
pure out-door air night and day; (b) an abundance of nour- 
ishing food; (c) rest in the open air, all the time if the patient 
is febrile, and at least a portion of the time if afebrile; (d) 
proper disposal of the sputum to avoid reinfection; (e) com- 
batting all symptoms or conditions which interfere with the 
main treatment. 

Whether the treatment should be conducted in a sana- 
torium, at one's home, or elsewhere in an open resort, must 
be decided by individual conditions, such as the domestic and 
pecuniary circumstances, the character, temperament, age, 
and the opportunity of securing competent medical super- 
vision. With some patients of weak will, and in an indul- 
gent family, it would be well nigh hopeless to prosecute the 
treatment with success at home. Although the essentials 
of the treatment are simple and few, they must be rigorously 
adhered to, and the patient must be where this can be done. 
One of the absolutely essential elements in the treatment is 
the education of the patient in the method of life he is to 
pursue, and this education or training must be immediate, 
prolonged, and constantly reiterated. 

Sanatorium or Outside Treatment 

On the other hand, one should not off-hand advise the 
sanatorium for every case, for not every patient, for one 
reason or another, is suitable for institutional treatment, and 
some will not go and others cannot. For the majority of 
patients, however, a good sanatorium probably offers the 
best chances. If the physician and patient decide upon the 
sanatorium, they should be assured that its equipment, man- 
agement, and medical direction are satisfactory; and of espe- 



112 PULMONARY TUBERCULOSIS 

cial importance is the character and skill of the physician in 
charge. Excellent results have been and can be obtained 
in an open resort, like Saranac Lake or Asheville, or at one's 
home, if the services of a skilled physician are at hand; for 
the constant supervision of a competent physician is one 
of the prime essentials of the treatment. 

Rest in Febrile and Afebrile Cases 

For the first two or three weeks at the commencement of 
the treatment, every patient should be kept at rest, whether 
or not he is febrile, in order that an accurate estimate of his 
condition may be obtained and his future plan of treatment 
be determined. Such rest is also of much value to the 
patient in enabling him to get a "start." If the patient is 
febrile, i. e., has an afternoon temperature of 99.5 F, or over, 
accompanied by constitutional symptoms, indicating active 
toxaemia, he should be confined strictly to bed, under exactly 
the same conditions as with a typhoid fever patient, "as com- 
pletely immobilized as possible." No exercise is to be al- 
lowed until the temperature becomes and remains normal. 
Exercise is only permissible when the patient is afebrile 
and free from all constitutional symptoms. With febrile 
patients sometimes the cough, which means severe exer- 
cise of the respiratory muscles, is so troublesome and harass- 
ing that it interferes with proper rest, and something may 
have to be done to alleviate it. Usually, the open-air life 
suffices ; if not, either some simple sedative may be employed, 
or, as a last resort, some of the milder preparations of opium, 
such as the following: 

Heroin grs. ii (0.13) 

Syr. tolu. 

Aquae distill, aa g ii (60.) 

nt Sig. 3i t.i.d. 
fy Dionin grs. v (0.32) 

Aquae amyg'd. amar. oiss (45.0) 

Aquae ad. §iii (90.) 

TTL Sig. 3i t.i.d. 




Fig. 13. Inexpensive sleeping balcony in a country house 




Fig. 14. Sleeping tent on roof (case in Boston) 



TREATMENT 113 

Or dionin J4 gr. tablets, heroin 1-24 to 1-12 gr. or codein */& 
to % gr. tablets. These should be discontinued, of course, 
on the amelioration of the cough. If the temperature is not 
above 99 , rest should be enjoined but not necessarily bed 
rest. 

The Out-Door Life 

The first requisite in the treatment is the provision for the 
out-door life, both by day and night. Some kind of a sleep- 
ing porch can generally be devised, a piazza utilized, or a 
tent or simple structure in the yard or on the house top, ar- 
ranged for the out-door sleeping. 1 (Figs. 13-19.) 

Occasionally it will be found that one cannot sleep well 
out of doors; he is nervous, and is unable to keep comfort- 
ably warm. Under these circumstances, a well ventilated 
room with open windows is preferable. In the colder 
months of the year one should wear warm night clothes 
with woolen socks and have sufficient light bed covering, or 
a sleeping bag, and, if needed, a heater for the feet. A sim- 
ple device for preventing the heat of the body from escap- 
ing below, and keeping out the wind, is several layers of 
newspaper placed under the mattress, or between two mat- 
tresses. If a piazza is used for out-door sleeping, some pro- 
tection from the wind should be afforded. One should dress 
and undress in a warm room. If the morning light awakens 
one too early, a shield for the eyes can be used, and about as 
good as anything for this purpose is a long black stocking 
loosely tied over the eyes. The habit of out-door sleeping 
is soon formed, and the sleep is so much more refreshing 
that one rarely desires to return to in-door conditions. With 
febrile cases, where one is in bed all the time, either the 
out-door sleeping porch or a well-ventilated room with open 
windows can be employed, preferably the former. 

By day, during the rest periods, one can sit on the piazza, 
in the yard or on the house top, wherever the air is free and 
there is sunshine. During the cold weather, he must be well 

(1 The reader is referred to "Fresh Air and how to use It" by Carrington, 
published by the National Association for the Study and Prevention of Tuber- 
culosis, 1912, for many valuable suggestions and illustrations with reference 
to out-door sleeping.) 



114 PULMONARY TUBERCULOSIS 

protected, both as to inner and outer clothing. A fur coat 
is the best outer covering; and woolen stockings, with high 
arctics, felt shoes, or sheepskin moccasins will keep the feet 
warm. A reclining chair, such as a ship's deck chair, is pref- 
erable; or if an ordinary chair is used, a common soap box 
into which the feet are placed will protect them from the 
wind and cold. When very cold, a knitted hood can be worn 
on the head and fur gloves on the hands. Thus protected, 
one can defy almost any temperature. 

While at rest out of doors one can either do nothing or 
occupy himself with some light handiwork, such as knitting, 
basket-making, light wood-work, simple games or reading. 
The effect of the constant open-air life is often very strik- 
ing: the appetite and digestion are stimulated, weight is 
gained, sleep is sounder and more refreshing, nervous irri- 
tability disappears, and there is a general sense of well-being. 

The Food 

The nourishment of the patient should receive the most 
careful attention, and should be adapted to each individual 
case. If the appetite and digestion are normal and the pa- 
tient is not much under weight, three liberal meals a day 
with the addition of milk and plenty of bread and butter will 
generally be sufficient. A mixed diet, as in health, is the 
desirable one, consisting of the proper proportions of pro- 
teids, carbohydrates and fats : of the proteids, from 500 to 
700 calories; of the carbohydrates, 1200 to 1500 calories; 
and of the fats, 1300 to 1500 calories. If an increase in the 
amount of fats is indicated, these can be given in the form 
of butter, cream, olive oil, and other animal and vegetable 
fats. 

The food should be varied, well cooked, and served, so as 
to be attractive and appetizing, and it should be taken at 
regular times. If the patient is much under weight or can- 
not eat a full meal, supplementary meals or simple lunches 
can be taken between the regular meals, consisting of milk 
and eggs, bread and butter, broths, cocoa, or other simple 
nutritious nourishment. If milk in its natural state is dis- 




Fig. 15. Sleeping porch (Carrington) 



TREATMENT 1 1 5 

tasteful or causes digestive disturbances, it can be modified 
in various ways: some alkali, as lime water, Apollinaris, or 
Vichy water may be added; it can be peptonized, or mixed 
with the malted milk preparations, or taken in the form of 
kumiss, buttermilk, gruel, junkets, whey, etc. 

Very often it will be found that more or less anorexia and 
digestive disturbances exist, in which event special dietaries 
will have to be arranged and the appropriate means taken 
to correct the dyspeptic symptoms. Constipation is one of 
the most common complaints, and it should be relieved, if 
possible, by means of the diet: stewed prunes, made more 
laxative by cooking them with senna leaves ; stewed onions, 
rhubarb, laxative fruits and vegetables, bran bread, cream 
or more fat of other kinds are useful for this purpose. A 
glass of warm water before meals is another expedient. If 
these measures do not avail, some of the simpler laxatives 
may be employed, such as the purified liquid petroleum, 
Agar, cascara sagrada, or one of the laxative waters or salts. 
Sometimes special diets or food preparations may be re- 
quired for a while, but every effort should be made to return 
to the ordinary mixed diet as soon as possible. 

The physician cannot be too painstaking in supervising 
the diet of the consumptive patient as to quality, quantity, 
the proportions of the food constituents, proteids, carbohy- 
drates and fats, and their preparation, for "the consumptive 
who does not eat is a consumptive lost." No perfection 
of the open-air treatment will avail unless the patient is well 
nourished. Rest before and after meals, especially the noon 
meal, should be the rule. The teeth must be kept in order 
and clean, for "well masticated is half digested/' Before 
meals the mouth should be cleaned with some mild antiseptic 
solution, and after meals the teeth should be brushed. 

Suggestive Articles of Diet 

(All food must be properly cooked and well served) 

The following suggestive articles of diet will be a useful 
guide : 



Il6 PULMONARY TUBERCULOSIS 

Beef (rare) roast; steak; mutton (roast), chops; fowl; 
bacon; good sausages; minced meat; cold meat and fowl; 
sweetbreads; eggs (raw, poached, boiled). Vegetables, 
such as baked potatoes, peas, string beans, spinach, aspara- 
gus, etc. Fish; soup (thin at dinner). Bread and butter, 
rolls, corn meal bread, bran bread, rye bread. Cream or milk 
toast; cereals with cream and sugar. Soft boiled rice with 
cream. Farinacious puddings ; ice-cream. Cheese. Salads, 
with oil dressing; sauces in which butter is the principal 
ingredient. Fruit, raw or cooked, as baked apples, stewed 
prunes, marmalade. Oatmeal gruel. Coffee (moderate), 
tea, cocoa, milk. (A glass or more of milk at each meal, and 
between meals, if ordered.) Good water plentifully taken 
at and between meals. 

Exercise 

All febrile patients, as has been said, must be kept 
absolutely at rest, and all afebrile patients must have 
periods of rest, especially when the vitality is low and the 
patient is under weight. There comes a time, however, 
when some exercise is allowable and beneficial; but it must 
be prescribed by the physician as to the kind and amount, 
and carefully supervised. The condition which permits ex- 
ercise is that in which the patient is free from fever and con- 
stitutional symptoms ; when the active stage of the disease 
has passed and he is on the road to an " arrest." The su- 
preme test that exercise is beneficial and not harmful is the 
absence of any rise of temperature or increase of pulse rate 
a half hour or an hour after the exercise, and of any consti- 
tutional disturbances, such as headache, lasting fatigue and 
a general feeling of weakness and malaise. When these 
symptoms occur, all exercise should be intermitted for sev- 
eral days. Walking is the best form of exercise to begin 
with, taken on the level at first, and, later, on very gradual 
ascents. The length of the walk must be definitely deter- 
mined by the physician. Various other forms of exercise or 
work, such as can be gradually increased from a little and 
light to a longer period and more severe, can be engaged 






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Figs. 16, 17. Simple sleeping porches (Carrington) 



TREATMENT 1 17 

in. To ensure success and avoid mishap, all work should be 
carefully graded, going on from step to step. The patient's 
condition, tastes and circumstances will often suggest the 
especial form of exercise. It may be some useful employ- 
ment, such as light farm work, gardening, book-binding, or 
a limited amount of house work for women. In sanatoria 
so-called "occupational therapy" is much in vogue at the 
present time and apparently with excellent results. 

In determining the time to begin exercise in the course 
of the treatment, each individual case must be considered 
by itself. In general, we can say that exercise is beneficial 
at that stage of the disease when the strength and weight 
have increased, and there is no fever or other symptoms in- 
dicating toxsemic activity. The proof of benefit from the 
exercise is continued improvement in the general condition. 
When the proper time comes for exercise, it should be begun 
as an integral part of the treatment, for when the recovery 
is achieved, the patient should be ready to again take his 
place in life's activities. 

Violent forms of exercise, such as horseback riding, ten- 
nis, dancing and rowing are unsafe. Golf, however, is allow- 
able, and it has the advantage of being easily graded, as one 
can be given only a certain number of holes to play. Gym- 
nastic and breathing exercise are of doubtful value and may 
do harm, and it is safer not to employ them. If there is 
doubt regarding the question of exercise, it is well to remem- 
ber that no harm can be done by rest, but that "more con- 
sumptives kill themselves by taking too much exercise than 
in any other way." 

Clothing 

Little need be said upon this subject. Such clothing 
should be worn as will make the patient comfortable and 
no more. The clothing should be evenly distributed over 
the body, and no greater thickness, such as chest protectors, 
vests or sweaters, should be worn over the chest than else- 
where. Too heavy clothing only overburdens one and 
causes him to perspire more easily; generally, however, the 



Il8 PULMONARY TUBERCULOSIS 

patient is rather more susceptible to cold and needs to dress 
a little warmer than in health. Light woolen or merino 
underclothing is advisable and should be loose enough to 
permit a circulation of air beneath it. The undergarments 
worn during the day should be removed at night and 
thoroughly aired, and they should also be changed if one 
gets overheated and perspires. For out-door use in winter 
a fur coat is the warmest. 

The Cold Bath 

A warm soap bath for cleanliness should be taken once or 
twice a week and in addition a cold sponge or shower bath 
in the morning on getting up if a speedy reaction occurs 
thereafter. If, on the contrary, there is a failure to react, 
as indicated by chilliness, lasting a considerable time, after 
the bath, blueness, "goose-flesh," and a feeling of depression 
instead of one of invigoration, the bath should be abandoned 
or milder hydrotherapeutic measures employed until one is 
able to endure the more rigorous form. The cold bath is a 
hardening process, its object being to stimulate the periph- 
eral nerves, increase the appetite, improve nutrition and 
assimilation, and to produce an invigorating effect on the 
body as a whole. The temperature of the water should be 
from 70 to 6o° F. or even 55 . Simple means can easily 
be obtained for taking the cold bath. All that is really 
requisite is a tub of some kind, a large sponge and a coarse 
towel. Salt may be added to the water to increase its 
stimulating effect. One saturates the sponge with water, 
and squeezes out the whole amount in a shower down the 
back and front, as he stands in the tub; this procedure is 
rapidly repeated over all parts of the body for about half 
a minute; he then rubs himself dry with the coarse towel. 
Instead of the sponge, a pitcher of water can be poured 
over the body, or a hose with a spray attachment can be 
connected with any convenient faucet in the house. 

With some patients, one has to begin gradually and work 
up to the cold bath : at first, with dry rubbing morning and 
night; later with moist rubbing by means of a wet, coarse 




Fig. 18. The Dunham bed, showing how head may project out of 

window 




Fig. 19. The Millet Sanatorium at East Bridgewater. Shack used 
for treatment of tuberculosis 



TREATMENT 1 19 

cloth or by enveloping the patient in a wet sheet and rub- 
bing him over it, until, finally, the stage of the ordinary cold 
bath is reached. If there is a tendency to hemorrhage, 
there is danger in the cold bath and it should be omitted. 

The Psychology of the Patient 

It is obvious that tranquillity of mind and contentment are 
essential in order to realize the best results from the treat- 
ment. " The consumptive must be treated in toto" says 
Dettweiler, "and his moral and mental education is quite as 
important as his bodily treatment." To secure this, much 
depends upon the personality of the physician; he must be 
able to inspire his patient with hope and courage. Every- 
thing which has a tendency to produce nervous and mental 
excitement, such as domestic or financial worry, or excit- 
ing literature, should be sedulously avoided. Some simple, 
soothing diversion is often of assistance in distracting the 
patient's thoughts from his malady. Such are games of soli- 
taire, simple, light occupations, like knitting, raffia work and 
the like, or an amusing story. When the condition permits 
occupational therapy training for one's future occupation is 
a mental stimulus of high value. Music is one of the best 
means of soothing and diverting the patient. I recall a visit 
to a German sanatorium where one of the features was a 
band concert several times a week. 

"When griping grief the heart doth wound, 
And doleful dumps the mind oppress, 
The music with her silver sound, 
With speedy help doth lend redress." 

Often a talk with the physician will relieve a depressed pa- 
tient and inspire him again with hope. A firm religious faith 
is a precious asset, yielding that peace of mind and restful- 
ness of spirit which " passeth understanding." 

Personal Hygiene 

The consumptive must maintain absolute cleanliness. 
The hands should be washed before each meal, the mouth 
cleansed, and the nails kept well manicured. The sputum 



120 PULMONARY TUBERCULOSIS 

should never be swallowed, and none should be allowed to 
soil his body or bed clothes or anything he handles. When 
coughing, one should hold something before the mouth. 
Any carelessness in disposing of the sputum may cause a 
reinfection or the infection of some one else. If a mustache 
or beard is worn — which is not advised — this should be 
washed several times daily. In brief, everything on and 
about the patient, or used by him, should be kept scrup- 
ulously clean. 

Osier's Summing Up 

Osier thus succinctly and admirably expresses the sum 
and substance of the treatment : 

"First: The confidence of the patient; since confidence 
breeds hope." 

" Second : A masterful arrangement on the part of the 
doctor." 

"Third: Persistence. Benefit is usually a matter of 
months; complete arrest a matter of years." 

" Fourth : Sunshine by day ; fresh air night and day." 

" Fifth : Rest while there is fever." 

" Sixth : Breadstuffs and milk, meat and eggs." 

The following is an illustrative daily plan of life for an 
afebrile patient of fair resistance and with few if any con- 
stitutional symptoms : 

7 a. m. Arise; a cold sponge or shower bath. Dress in 
a warm room. 

7.30 or 8 A. M. Breakfast, and afterwards rest in a reclin- 
ing chair, or a walk or other exercise if prescribed. 

11 a. m. A light lunch, if ordered, consisting of a glass 
of milk and egg, or some simple articles of food. 

12 m. to 1 p. m. Rest. 
1 to 1.30 p. m. Dinner. 

1.30 or 2 p. m. Rest for an hour; later, a walk or other 
exercise. 

4 p. m. A light lunch if ordered. 



TREATMENT 121 

4 to 6 p. m. Rest or exercise as prescribed, but a half 
hour's rest before the evening meal. 

6 p. m. Supper. 

6.30 to 9 p. m. Simple recreation of some kind or rest. 

9 p. m. Retire. 

Of course the daily routine must obviously be arranged 
according to the special conditions of each individual. 

" Suggestions and Aids " 

I have been accustomed to hand the following brief sug- 
gestions to my patients, based largely upon similar ones de- 
vised by Dr. Minor of Asheville : 

(These suggestions are general and not intended to take 
the place of the physician's advice for your special condition.) 

" The labor which best repays a sick man is to get well." 

"If treatment is begun early most cases of tuberculosis can 
be cured, but it requires determination, perseverance, and 
often self-denial to accomplish it. 

"There are four (4) essentials in the treatment: (1) Com- 
petent medical guidance; (2) fresh air; (3) good food; (4) 
rest. There are no known medicines or specifics which will 
cure tuberculosis; therefore, do not take any drugs except 
what may be ordered by your physician for certain special 
symptoms. 

"Whether the treatment in your case can be best carried 
out in a sanatorium, at home or by going to a health resort, 
must be decided by your physician. 

"Most patients must devote their entire time to getting 
well, at least in the beginning of the treatment, for it requires 
constant attention to learn and become accustomed to the 
new method of living, which we call the 'open-air treat- 
ment, or the 'cure.' " 

Rest 

"Rest is very important in the 'cure,' and, if there is fever 
— a temperature of 99.5 or over — it should be absolute, and 
you should recline on a cot or reclining chair out of doors, 



122 PULMONARY TUBERCULOSIS 

or in bed with windows wide open. Even if there is no 
fever, you should spend a good deal of time at rest, especial- 
ly at the beginning of the treatment. You can do this by 
sitting or reclining on a piazza or wherever fresh air can be 
obtained and protection from the wind secured. 

The Outdoor Life 

"After the habit has been formed you should spend from 
seven to ten hours out of doors daily, winter and summer. 
When it is cold, dress warmly and use sufficient wraps to be 
comfortable. Keep in the sun, but protect the head from it. 
The outdoor life can be continued at night by sleeping out 
of doors, either on a piazza, in a sleeping porch, or by using 
a window tent. Night air is as good as day air, and some- 
times better. In sleeping out of doors, you must have suffi- 
cient covering and warm night clothes, a flannel nightdress, 
or pajamas, woolen stockings, a Jersey or 'sweater/ a 
woolen hood or helmet, and a hot water bottle or soap stone, 
if necessary, to keep warm. If you sleep in a room, have a 
large one with two or more windows, facing South, South- 
west, or Southeast, and if possible, with an open fireplace in 
it. When in the room and not in bed have the temperature 
from 65 to 68, unless dressed as for out of doors. Dress and 
undress in a warm place. Sleep alone, and if possible oc- 
cupy the room alone. Have the room plainly furnished 
with few things in it, so that it can be easily cleaned and 
kept clean. Go to bed early, at 9 or 9.30 p. m." 

Clothing 

"Wear such clothing as will keep you warm, but not such 
as will be a burden to carry about and cause you to perspire 
at any little exertion. Wear wool or merino next to the 
skin. Do not wear chest protectors.' Woolen stockings 
and low shoes will often keep the feet warmer than cotton 
stockings and boots. For outdoor use an ulster or fur coat 
is very serviceable. If you get overheated and perspire 
change the clothes and rub the skin dry. Never be chilly. 



TREATMENT 1 23 

Bathing 

"Take a warm bath once or twice a week at bedtime. A 
cold sponge bath on getting up in the morning, as ordered 
by the physician. If you do not react, or feel chilly after 
the cold bath, or feel sick in any way, stop the bath and 
consult your physician. Take the cold bath in a warm room. 
If you have night sweats take a rub with vinegar and water 
at night, and a glass of hot milk. If you are frequently 
chilly, take an alcohol rub. ,, 

Food 

"If the digestion is good, eat three good meals a day, con- 
sisting of soup, meat, vegetables, bread and butter, milk, 
cream, eggs, articles of food containing fat or prepared with 
fat or oil, fruit, etc. Your physician may also order in addi- 
tion to the three meals simple lunches at n, 4 and bed-time, 
consisting of milk, raw eggs, bread and butter, cocoa, choco- 
late, soup, etc. Do not eat cake or pastry. Rest an hour 
before and be quiet an hour after meals. Eat slowly and 
chew the food thoroughly; therefore, see that your teeth are 
in good condition. Drink the milk slowly or sip it. If you 
think you are overeating from any feeling of distress after 
meals, or from any indication of indigestion, consult your 
physician. The food must be abundant, nourishing, and 
prepared in an appetizing manner. Your salvation lies in 
food, properly prepared, and in a stomach capable of digest- 
ing the food. Be regular at your meals and try to enjoy 
them. Eat with others, and converse with others, rather 
than eat alone. Have your physician prepare a bill-of-fare 
for you. Drink pure water, and never take alcoholic stimu- 
lants unless prescribed by your physician." 

Cough and Expectoration 

"Never spit anywhere except in a cuspidor with water or a 
disinfectant in it, or in a spit-cup, pocket spitoon, or a paper 
napkin which then can be put in a paper bag and burned. 
The best way of destroying the sputum is to burn it. In 



124 PULMONARY TUBERCULOSIS 

coughing, hold a cloth or paper napkin before the mouth; if 
a handkerchief is used, do not let it get dry, and wash it in 
boiling water. Ineffective coughing — that which does not 
bring up sputum — is useless, tiresome, and renders one con- 
spicuous. Therefore, try to control and repress such a 
cough, which you can do by practice. Never swallow the 
expectoration, as it may cause further infection. Always 
wash your hands before eating; clean your teeth, and wash 
out your mouth and nose several times a day. If any ex- 
pectoration should, by accident, get on the floor, or on any 
article of clothing or furniture, it should be wiped up at once 
with soap and hot water, or with a five per cent, solution of 
carbolic acid. Whatever increases the cough, refrain from 
doing. A clean consumptive is a safe consumptive." 

Exercise 

"In your own special case, follow the advice of your physi- 
cian; in general, at the beginning of the treatment, it is us- 
ually best to keep pretty quiet. Never exercise if there is 
fever, if the temperature is over 99.5 . Never to the point 
of fatigue. No exercise for an hour after meals, and none 
if the sputum is streaked with blood. No gymnastic or 
breathing exercise unless ordered by your physician. Walk- 
ing is usually the best and safest exercise, at least until the 
'cure' is well advanced. No violent exercise or such as 
causes you to feel uncomfortably short of breath." 

Maxims and Random Hints 

"When in doubt about anything, consult your physician; 
take no chances. 

"Do not talk over your case with any one but the doctor. 

"A hemorrhage (spitting blood) is generally not a very 
serious symptom; if you have one, go to bed and keep very 
quiet and send for your physician. 

"It takes time to make the 'cure,' so do not be impatient 
to get well; a good cure is often a slow cure. 

"The instructions given you by your physician should be 
followed out in every particular." 



TREATMENT I25 

"A person suffering from tuberculosis is not dangerous to 
live with if he promptly destroys the sputum and covers his 
mouth when coughing. 

"A hopeful, cheerful disposition is one of the best remedies 
for pulmonary tuberculosis. 

"Your most important duty is to get well. Let all other 
duties be secondary. 

" 'Whatever thou takest in hand remember the end, and 
thou shalt never do amiss/ 

'Whatever is worth doing is worth doing well.' ' 
'Where sunlight enters not, there the physician goes/ 
" 'It is part of the cure to wish to be cured/ 
"The important essentials in the treatment of your disease 
are: Out-of-door life, winter and summer, day and night. 
Have no fear of night air, and none of draughts, provided 
you are properly protected. Avoid damp houses or rooms, 
and crowds, smoke and dust. Avoid all excesses. Eat 
plenty of good, nourishing food. Drink plenty of good 
water, but no alcohol. Be careful not to exercise when you 
should rest. Take no drugs except on the advice of your 
physician. Keep the body clean. Never swallow the spu- 
tum. Be hopeful and cheerful." 

Special Directions of the Physician 

Take your temperature at 

Lunches at 

Consisting of 

Hours out of doors 

Exercise 

Bathing 

Day's Plan to be Filled Out by Your Physician 

7 or 7.30 a. m 

7.30 or 8 a. m 

8.3O tO 1 1 A. M 

1 1 A. M 

I I.3O A. M. tO I P. M 



126 PULMONARY TUBERCULOSIS 

1 tO 2 P. M 

2 tO 4 P. M 

4 P. M 

4.30 to 6 P. M 

6 to 7 p. m 

7 to 9 or 9.30 p. m 

9 or 9.30 p. m 

Medicine, if any. 

Treatment of Advanced, Hopeless Cases 

The main thing to be done for these deplorable cases is to 
make them physically comfortable, and everything which 
conduces to this should be allowed. Fresh air, they should 
have; but unless they desire it, they should not be exposed 
to the rigors of outdoor life in the colder season of the year. 
A comfortable bed in a well ventilated room is generally 
preferable. All the innumerable symptoms constantly com- 
plained of or imagined should be met with kindly attention 
and patience. If pleuritic effusion occurs, as it not infre- 
quently does, it is not to be aspirated unless there is immedi- 
ate danger of a fatal result, or it causes great distress. 
Sometimes the effusion renders the patient more comfort- 
able or tends to retard the disease on the same principle as 
artificial pneumothorax. If the cough is harassing and pre- 
vents sleep, codein, heroin or dionin may be used, or some- 
times the mild tincture of opium (tr. opii camph.) acts 
admirably. 

The diet should be simple and easily digestible, such as 
milk and milk preparations, broths, custard, milk toast, etc. 
Anything which the patient desires and which does not dis- 
tress him may be allowed. 

If dyspnoea is a marked symptom, as it often is, besides 
absolute rest in a comfortable position, relief may be ob- 
tained from some of the diffusible stimulants, such as the 
aromatic spirits of ammonia, "Hoffman's anodyne," cham- 
pagne, or the inhalation of oxygen gas. Strychnia is also 
of value for this condition. Generally, opium in some form 
will have to be pretty constantly employed, as it is, perhaps, 



TREATMENT 127 

the one best reliance for such cases, and should not be with- 
held from these hopeless, pitiful sufferers. 

The following are some of the significant therapeutic 
theses of Dr. Brown: 

Therapeutic Theses 

i. "The tendency to recover in some patients is so marked 
that it ensues in spite of the most injurious treatment." 

2. "There is no disease for which the medical profession 
can do so little actively as for steadily advancing pulmonary 
tuberculosis." 

3. "The treatment of pulmonary tuberculosis demands 
little knowledge of drugs, but much about the immediate 
and prolonged education of the patient." 

4. The idea that pulmonary tuberculosis is a most curable 
disease is a fallacy." 

5. "The time allotted to treatment is usually too short, for 
recovery is ever longer than onset. The value (possibly the 
results) of treatment increases as the square of the time, 
that is, two years are four times as valuable as one, but the 
struggle lasts often from diagnosis to death." 

6. "The physician must have imagination, sympathy, firm- 
ness, approachableness, as well as knowledge of the disease 
of the individual patient, his psychological and his sociologi- 
cal condition, and last but not least, of the limitations of his 
own knowledge." 

7. "At home and abroad, in the desert or on the ocean, in 
the lowlands or upon the mountains, patients may do well, 
as they recover anywhere and everywhere, for it matters less 
where than how they live." 

8. "For those who spend at least eight hours out of doors, 
sleeping out does not hasten recovery provided they sleep 
in well-ventilate rooms, but for those forced to be indoors 
during the day it is a 'sine qua non' of continued arrest." 

9. "Give your patient as little food as will serve his pur- 
pose and have clearly in mind what this purpose should be : 
to gain up to, and ten to twenty pounds beyond, his usual 
weight." 



125 PULMONARY TUBERCULOSIS 

10. "Remember that too much food may in the end prove 
as disastrous as too little food." 

ii. "When anorexia appears upon the horizon, and simple 
tonics cannot dispel the 'bugaboo,' do not fail to resort to 
fluids, and fluids only without a bite to chew." 

12. "Insistence upon absolute rest and its observance for 
six weeks affords rest for repairs, time for growth of scar 
tissue and opportunity for the walling off of areas of disease 
in the early stages. Such periods of rest in later stages 
accomplish no such results." 

13. "Exercise should be regarded as a powerful and dan- 
gerous medicine to be used carelessly never, with impunity 
by none, and as a deadly drug by all." 

14. "Since the vast majority of the patients must seek 
treatment only in the climate in which they contract the disease, 
the so-called climatic treatment is of importance to hardly 
more than five per cent, of all patients." 

15. "It is criminal to advise an untrained patient to seek 
benefit from climatic change without constant medical 
advice." 

16. "As a rule a patient should be sent (if sent away at all) 
to as cold a climate as he can react to and enjoy." 

17. "There is as yet no accredited specific (like '606' in 
lues) for tuberculosis." 

18. "Drugs may alleviate or even remove for the time 
being certain localizing and constitution 1 symptoms but 
affect in no direct way the disease that produces them." 

19. "Beyond the empirical fact that many patients do bet- 
ter for some change, much has been written but little proved 
about climatic treatment." 

20. "The tubercle bacilli or their products, otherwise 
known as tuberculin, the most widely used of all so-called 
specific agents, have not given, when subjected to cold im- 
partial statistical study, the results claimed by the enthus- 
iasts." 

21. "The effect of tuberculin upon any individual symp- 
tom or patient is at present most uncertain, and in all com- 
parisons of treatment the time element and the selection of 
patients must be carefully considered." 



CHAPTER IX 
ESPECIAL METHODS OF TREATMENT 

" All methods of treatment end in disappointment of those extravagant 
expectations which men are wont to entertain of medical art." 

O. W. Holmes. 

Various anti-tuberculosis serums and innumerable drugs 
and special methods of treatment have been and still are 
brought forward by their enthusiastic advocates, as exer- 
cising a specific influence upon tuberculosis, either by their 
inhibitive or destructive influence upon the tubercle bacillus 
and its toxins, or by their influence in promoting the forma- 
tion of fibrous tissue, such, for example, as creosote, arsenic, 
mercury, iodine, the alkaline hypophosphites, raw meat and 
raw meat juice, and many others. None of these "short- 
cut" methods of arresting the disease, however, has proved 
of any specific value, and, from the nature of the disease, 
probably no specific ever will be discovered. There are two 
especial methods of treatment used in connection with the 
usual hygienic-dietetic measures which have established 
themselves as of more or less value in selected cases by long 
experience and observation. They are tuberculin and arti- 
ficial pneumothorax. » 

Tuberculin 

Tuberculin, first originated by Koch, is the product de- 
rived from cultures of the tubercle bacillus, either in the form 
of the filtered extract of the bacillus, containing its dissolved 
toxic products, as in Koch's old tuberculin, (O. T.), or it may 
be composed of the pulverized insoluble substance of the 
bacilli themselves, the "bacillen-emulsion" of Koch. There 
are very many tuberculins depending upon the various 
methods of preparing them, but they are all essentially the 
same and act in the same way. Probably Koch's old tuber- 

129 



I30 PULMONARY TUBERCULOSIS 

culin, (O. T.), and his bacillen-emulsion, "new tuberculin" 
(" B. E."), are the most frequently employed in the thera- 
peutics of tuberculosis, although each variety has its advo- 
cates. Whatever the method of production employed, or 
the exact composition of the tuberculin, it contains, of course, 
no living tubercle bacilli. 

The theory of the action of tuberculin is that active im- 
munity is produced, — not immunity to the tuberculosis, as 
anti-diphtheritic serum does to diphtheria, — that is, passive 
immunity; but a stimulation of the defensive powers of the 
body is produced, and more anti-bodies are formed to con- 
tend with the toxins of the bacilli. The action of tuberculin 
is solely towards the specific infection, and it has no effect 
upon a healthy person. It is not a cure; only in properly 
selected cases it may be said to be a favorable factor, how 
favorable we cannot say. 

Trudeau, the famous physician of Saranac Lake in the 
Adirondacks, from his long and extensive experience, thus 
conservatively states the case: "My experience with the 
tuberculin treatment thus far has led me to believe that when 
carefully applied in suitable cases it has seemed to have 
some favorable influence in bringing about healing of the 
lesion." 

The suitable cases for the use of tuberculin are those in 
which there is a fair degree of resistance and in which the 
general condition is good, and in this class are included (a) 
early cases with small local lesions; (b) moderately ad- 
vanced cases which have remained stationary under the 
usual hygienic-dietetic treatment; and (c) cases in which 
the physical signs are extensive, but with slight constitu- 
tional symptoms. Mild fever is not a contraindication if 
the nutrition is good. The fundamental condition in all 
cases for the use of tuberculin is that there should be a fairly 
good resistance; otherwise, the tuberculin will do harm. 
Tuberculin can be safely employed in ambulant cases, as is 
done in many clinics, and in the doctor's office; but the pa- 
tient must be perfectly able to come to, the dispensary or 
office. 



ESPECIAL METHODS OF TREATMENT I3I 

The technique of the tuberculin treatment is now easy, 
since the proper dilutions can be readily obtained from repu- 
table firms. The main point to bear in mind is to begin with 
small doses and increase so slowly that no reaction occurs. 
Having selected the tuberculin to be used, for instance, 
Koch's old tuberculin, (O. T.), one begins with a dose of 
0.000.0001 c.c. to 0.000,001 c.c. and gradually increases it by 
twice the first dose, then three times, four times, etc., the 
first dose, until finally the maximal dose of i.o c.c. is reached, 
which is usually in about six months. The intervals be- 
tween the doses is generally three or four days, and this 
interval is maintained as long as the patient is doing well. 
If, however, a slight reaction should occur, the interval 
should be increased to one week, and the dose diminished. 
A subcutaneous syringe graduated in tenths of a c.c. is em- 
ployed, the dose being so many tenths of a c.c. of the dilu- 
tion used. The injection is preferably given in the back at 
the angle of the scapula, and the usual antiseptic precautions 
observed. If a reaction occurs, it is indicated by a rise of 
temperature, a loss of weight, headache, and general malaise, 
a focal reaction by changes in the pulmonary signs, and, 
locally, by pain, tenderness or swelling at the site of injec- 
tion. Of the general reaction, the most important signs 
are fever, loss of weight and general depression. 

If the tuberculin treatment is successful, it is indicated by 
an improvement in the appetite and digestion, increase in 
strength and usually in weight. Other evidence of improve- 
ment may also be noted. 

When the higher doses are reached, the intervals can be 
longer, from two to four weeks. There can, obviously, be 
no fixed doses, as the resistance of the patient is an uncer- 
tain factor. Each one must be individualized, both as to the 
dose and as to its increase. 

The main object to be attained in the tuberculin treatment 
is to gradually increase the tolerance to it to the highest 
point attainable, avoiding reaction. It is well again to re- 
peat that tuberculin is not a cure, but only a favorable factor 
in certain cases, and it does not by any means take the place 



132 PULMONARY TUBERCULOSIS 

of the hygienic-dietetic treatment, but is only to be used in 
connection with it. With ordinary care and constant super- 
vision of the patient, tuberculin used according to the above 
precautions can with safety be used by any physician, but it 
must be confessed that its value is doubtful. 

Artificial Pneumothorax 

Artificial pneumothorax, as its name implies, is the pro- 
duction of a pneumothorax in the pleural cavity of the dis- 
eased lung for the purpose of collapsing the lung, and it is 
accomplished by injecting air or nitrogen gas, generally the 
latter, into the pleural space. The object to be attained is 
the immobilization of the lung, the promotion of the forma- 
tion of connective tissue, the collapsing of cavities, and a 
reduction of toxic absorption. It is applicable to only a 
limited number of cases, chiefly to those in which there is 
extensive unilateral (or chiefly so), progressive or chronic 
disease which fails to respond to the ordinary hygienic- 
dietetic measures. It has also been successfully employed 
in recurring or very severe hemorrhages which failed to yield 
to other treatment, provided, of course, it was determined 
from which lung the hemorrhage came. 

Artificial pneumothorax is, in one sense, a last resort in 
that it is chiefly applicable to those cases which, under any 
other treatment, seem doomed; and experience has shown 
that many such cases have been saved by it. This operation 
has also been recommended and, indeed, employed in earlier 
cases which appeared to have no recuperative power or 
showed no improvement under the ordinary measures of 
treatment. In far-advanced cases it has occasionally pro- 
duced an arrest of the disease, or an amelioration of the 
symptoms. The cases of choice, however, are those chiefly 
or entirely unilateral when there is still a fair amount of re- 
sistance, and such cases are comparatively few. 

It is not always possible to induce a pneumothorax on 
account of pleural adhesions. 

The operation in one sense is a simple one, so far as the 
operation itself is concerned, but it requires much experi- 




Fig. 20. Dr. Samuel Robinson's apparatus for artificial pneumothorax: 




Fig. 21. Illustrates a needle which Dr. Cleaveland Floyd has designed 
Kindness of Codinan & Shurtleff, Inc., 120 Boylston St.. Boston, Mass. 



ESPECIAL METHODS OF TREATMENT 1 33 

ence and careful manipulation in order that the lung may 
not be punctured and gas injected into the circulation, pro- 
ducing gas embolism. It is also quite essential that one 
should possess the knowledge which the X-ray picture of 
the chest gives, so as to select the most favorable site for the 
puncture and to determine the condition of the pleura as to 
adhesions, and subsequently to note the effect of the injec- 
tion, to be sure the gas is in the pleural cavity and to see 
how far the collapse has advanced. A special apparatus 
is also necessary, with a manometer to indicate by the oscil- 
lation of the fluid in it whether or not the needle is in the 
pleural cavity, and also the pressure. (Figs. 20, 21.) The 
operation is performed under careful antiseptic conditions 
and for the first weeks of treatment the patient as a rule 
should be kept quiet in bed. Local anaesthesia alone is 
required. The following solution being used: 

Novocaine 0.5 

Adrenalin 1.0 

TTt Aquas distill. 100. 

Or eucaine with adrenalin may be employed for the same 
purpose. Of the novocaine solution thirty minims is gener- 
ally sufficient. Not only the superficial parts but the pleura 
itself should be anaesthetized. Although the general physi- 
cian will usually refer the cases he thinks suitable for arti- 
ficial pneumothorax to the expert, still he should know some- 
thing about the operation and its effects, as well as what 
class of cases is likely to be benefited by it, in order that he 
may intelligently advise his patient. 

If the first application succeeds, and one feels sure he is in 
the pleural cavity, 200 to 300 c.c.'s of the nitrogen gas are 
injected and in a day or two the same amount or more, until 
gradually the lung is more or less fully collapsed. 

As has been said above, the patient should be kept quiet 
for several weeks until the changed conditions in the circu- 
lation from the pressure have adjusted themselves. Later, 
he can be up and, possibly, come to the clinic or office for 



134 PULMONARY TUBERCULOSIS 

the refillings which need only to be done at quite long inter- 
vals after collapse has once been well established. Com- 
pression should be maintained for a long time, — a year or 
more. 

If the operation is effective, the result is shown in a de- 
crease of the temperature and pulse rate, disappearance of 
night sweats, improved appetite and digestion, and a gen- 
eral feeling of well-being. The cough and expectoration 
may at first be increased, but after a few days decrease and 
may entirely disappear. 

So far as danger is concerned in the operation itself, one 
can say that, in skilled hands, if a careful technique is ob- 
served, it is practically free from danger; so that if it does 
no good, it will do no harm. 

The evidence now at hand abundantly proves the value of 
artificial pneumothorax as an additional weapon in the treat- 
ment of tuberculosis. As Prof. Saugman says: "It has 
fully justified its place in the treatment of some severe cases 
of pulmonary tuberculosis, and that by it recovery some- 
times may be obtained when any other treatment would 
have failed." 

Case of Artificial Pneumothorax 

C. S., aged 17, student. Family history: Mother suffered 
from some pulmonary trouble (tuberculosis?). Previous 
history: Well as a child with the exception of children's 
diseases. Has not been feeling well for a month or two. 
Has a slight cough but with no expectoration. The tem- 
perature is a degree or more above normal in the afternoon. 

On physical examination there was dullness and modified 
respiration at both apices and a few sticky rales at the left 
apex. 

Later he went to Saranac, and as after a continued trial 
of rest and the open-air treatment the acute symptoms per- 
sisted and the disease was rapidly advancing, artificial pneu- 
mothorax was done and the left lung collapsed and the com- 
pression maintained by successive refills." 

As a result the acute symptoms disappeared and he was 
enabled later to take unrestricted exercise. He also gained 



ESPECIAL METHODS OF TREATMENT 1 35 

10 pounds in weight. At a subsequent examination no evi- 
dence of activity was discovered. He had a slight cough 
but no expectoration. 

Here was a case in which the! acute symptoms persisted in 
spite of the usual open-air treatment and the disease was 
steadily progressing, and which was evidently arrested by 
the timely recourse to artificial pneumothorax. 



CHAPTER X 
TREATMENT OF SPECIAL SYMPTOMS 

" ' Fortune always leaves some door open in disasters, whereby to 
come at a remedy,' said Don Quixote." 

" The means that heaven yields must be embrac'd 
And not neglected; else if heaven would, 
And we would not, heaven's offer we refuse." 

Richard II, Act III, Sc. 2. 

Debility, Anorexia and Loss of Weight 

One of the prominent and early symptoms of pulmonary 
tuberculosis is debility, often accompanied by loss of weight. 
The first and most important step in the treatment of this 
condition is rest in the open air and proper and abundant 
food, rich in proteids and fats. It will often be found that 
a patient can take and digest a larger amount of food than 
in health if properly prepared and made appetizing, but it 
may have to be given in small amounts at frequent intervals. 
It is well in this connection to remember the saying of Dett- 
weiler, " My kitchen is my pharmacy." One cannot give too 
much attention to the food question of his consumptive 
patient. 

If the appetite is wanting, some of the bitter tonics may 
be employed, such as nux vomica, gentian, calumba, carda- 
mon, cinchona, often combined with advantage with the 
mineral acids or Italian vermouth. Again, the compound 
syrup of hypophosphites, or some of the malt preparations, 
will be of assistance. The following is recommended by 
Burton Fanning as particularly useful, both in stimulating 
the appetite and remedying various digestive disturbances, 
such as flatulence and distension: 

Sodii bicarb. grs. xv (1.0) 

Tr. nucis vomicae mvii (0.4) 

136 



TREATMENT OF SPECIAL SYMPTOMS I37 

Tr. gentianae 3ss (2.0) 

Aquae chloroformi ad §i (30.0) 

Til Sig. The above as a dose before meals. 

Constipation, if present, must be corrected by food or laxa- 
tives, as has been previously indicated, and digestive disturb- 
ances counteracted by appropriate treatment as will later be 
considered. 

Anaemia 

As a matter of routine, the blood should be examined both 
as to the percentage of hemoglobin, and the number and 
character of the red blood-corpuscles. If evidences of an- 
aemia are found — the secondary anaemia of tuberculosis — in 
addition to nourishment and fresh air, iron in some form is 
indicated. One can either employ some of the older prep- 
arations, such as the chlorid and carbonate of iron or the 
syrup of the iodid, or one of the many new preparations, 
such as ferro-mangan, ovoferrin, proferrin or triferrin. It 
is also to be remembered that a diet rich in iron, such as 
the yolk of an egg, whole wheat, red meat, green vegetables, 
etc., may furnish the needed iron. 

Arsenic comes next in importance to iron in the drug 
treatment of anaemia, and here we may employ either the 
simpler forms, such as arsenious acid 1-40 gr. dose, or Fow- 
ler's solution, beginning with 3 or 4 drops and gradually in- 
creasing to 7 drops; or some of the more complex prepara- 
tions, such as sodium cacodylate J4 to 2 grs. in pills or hypo- 
dermically, which is considered less toxic than the ordinary 
preparations of arsenic and less apt to cause digestive dis- 
turbances. Sodium arsenate 1-100 to 1-20 gr. or elarson y% 
gr. are other preparations. Arsenic and iron can also be 
employed with advantage in combination, and can be 
given subcutaneously in the form of citrate of iron .05 and 
sodium arsenate .001, the injections to be given in the gluteal 
region or in the deltoid muscle twice a week. Iron arsenate 
1-16-1-12 gr. arsenoferratin J 1 /* grs., three or four times a 
day, and arsentriferrin 5 grs. are other combinations. Strych- 
nia, an excellent nerve tonic, may also be combined with 



I38 PULMONARY TUBERCULOSIS 

one or both of the other two drugs, as iron arsenate and 
strychnia, or citrate of iron .05, sodium arsenate .001 and 
strychnia .001, or citrate of iron .05 and strychnia .001, given 
subcutaneously. These combinations for subcutaneous in- 
jection can be obtained in ampules. Hemaboloids arsen- 
ated with strychnia is said to be a favorable combination of 
the three drugs. 

Gastro-Intestinal Disturbances 

Digestive disturbances frequently occur in tuberculosis 
and are to be treated according to the indications very much 
as in other diseased conditions. As it is of the utmost im- 
portance that the tuberculous patient should efficiently di- 
gest and assimilate his food, careful and immediate attention 
should be given to any digestive irregularities. The main 
reliance should be upon a careful selection and preparation 
of the food. It may be necessary to have recourse to a test 
meal and examine the stomach contents, or investigate the 
dejections in order to determine the cause of the disturbance 
and the appropriate treatment. If constipation is present, 
that should be relieved. If the normal digestive ferments 
are defective in activity, and deficient in quantity, some form 
of pepsin, either alone or in combination with hydrochloric 
acid or lime juice, to which some of the bitter tonics can be 
added, is indicated. If there is much fermentation and 
gas, such remedies as creosotal one or two drops, pancreatin 
5 grs., salol 5 grs., charcoal, spirits of chloroform 20 minims 
to one fluid drachm, asafcetida 5 grs., the Bulgarian bacillus 
preparations, or a brisk cathartic are to be employed accord- 
ing to the indications. When there is gastric pain and dis- 
tress after eating, accompanied perhaps with nausea and 
vomiting, menthol 1 or 2 grs. and bismuth with bicarbonate 
of soda are useful. In every case the diet must be carefully 
regulated; fried and rich foods must be avoided and one may 
be obliged to have recourse to especially prepared food, such 
as milk with Vichy or Apollinaris water, kumiss, beef juice, 
etc. 

When there is a general nervous condition coincident with 



TREATMENT OF SPECIAL SYMPTOMS 139 

the gastric disturbance, or perhaps its cause, Bonney 1 strong- 
ly recommends the following as of value from a long experi- 
ence in its use : 

Strychnin 1-30 gr. (.00216) 
Salol 5 gr.' (.325) 

Aqueous ext. of opium, 1-10 gr. (.0065) 
Ext. cannabis indica 1-15 gr. (.0043) 
Aloin 1-40 gr. (.00162) 
TTL Sig. The above to be taken in capsule after meals. 

Vomiting 

This is a serious symptom, as it often entails the loss of a 
meal, and thereby interferes with the nourishment of the 
patient. It is caused either reflexively from the cough, or 
from irritability of the pharynx or from gastro-intestinal dis- 
turbance. Vomiting occurs frequently after breakfast, the 
taking of food excites coughing, and the coughing results 
in vomiting and the loss of the meal. To obviate this, a 
warm drink, such as a glass of milk, a cup of coffee or beef 
tea or Vichy or Apollinaris water is taken on awakening. 
The warm drink excites the inevitable morning paroxysm 
of coughing and clears out the accumulated secretions, and 
later the breakfast can be safely taken. If the pharynx is 
irritated, anesthesin, orthoform or novocaine can be applied 
locally. When there is gastric irritability anesthesin can 
also be employed internally, codein, oxalate of cerium or 
chloroform water. 

Diarrhoea 

Diarrhoea may occur in any stage of pulmonary tubercu- 
losis, either from digestive disturbances or from a tubercu- 
lous involvement of the intestinal tract. In the latter case 
it generally occurs in the late stages of the disease. If from 
digestive disturbances, the principal indication is the regula- 
tion of the diet; for a day or two a milk diet or milk foods 
with toast may be all that is necessary, first cleansing the 

1 " Tuberculosis and Its Complications," Phila., 1908. 



140 PULMONARY TUBERCULOSIS 

alimentary canal with castor oil or calomel. If medication 
seems indicated bismuth salicylate is perhaps the best rem- 
edy, a teaspoonful of the powder taken with meals. Tan- 
nigen 3 to 10 grs. (0.2 to 0.7) four times a day dry on the 
tongue, followed by a swallow of water or mixed with food, 
and tannalbin 15 to 60 grains (1.0 to 4.0) in powder or tab- 
lets, followed by water or in gruel, are other useful remedies. 
In the diarrhoea of tuberculous ulcerations the above reme- 
dies may be of avail; or others are oxid of zinc with bismuth, 
the lead and opium pill and the fluid ext. of coto bark. Irri- 
gation of the rectum is also sometimes beneficial. Great 
care should be taken with the diet, which should consist of 
bland substances, such as milk and milk preparations, arrow- 
root, meat broths, etc. 

Cough 

Cough is often such a prominent symptom that the patient 
thinks if he can obtain relief from it his disease will be equally 
benefited, and he, therefore, insists upon some cough remedy. 
One should be very cautious, however, about yielding to the 
patient's importunity unless there seems to be an imperative 
indication for therapeutic interference. Under the open-air 
treatment the cough often takes care of itself, and, further- 
more, the patient can be trained to suppress much unpro- 
ductive coughing, for like other constantly recurring acts, 
coughing becomes ofttimes a habit and is yielded to upon 
slight provocation, when not necessary for the removal of 
secretion. 

In spite of the general treatment, however, and the en- 
deavor to control it, the cough becomes so troublesome at 
times that some active interference is indicated. Treatment 
is necessary when (a) the cough is incessant, disturbing the 
rest of the patient and seriously dissipating his strength, for 
it must be remembered that coughing is violent exercise; 
when (b) the cough is ineffective, or hard, and it requires 
a continued paroxysm to expel the secretions; and when 
(c) the secretions are excessive and more or less continuous, 
coughing is necessary to get rid of them. Not infrequently 



TREATMENT OF SPECIAL SYMPTOMS I4I 

all three causes are operative. The object to be attained in 
treatment is to restrain the cough within the limits of effec- 
tiveness and lengthen the intervals. If the cough is hard 
and ineffective some expectorant is indicated, such as the 
chloride of ammonium or the aromatic spirits of ammonia, 
a teaspoonful of the latter in a glass of water and frequently- 
sipped is most useful. With these, codein or heroin may be 
combined. The syrup of hydriodic acid often advantage- 
ously combined with spirits of chloroform is another remedy 
of value for this condition. Inhalations of thymol, eucalyp- 
tus, pine needle oil, tr. benzoin comp. and creosote are other 
means which may give relief. 

When the secretions are excessive, such remedies as ter- 
pin hydrate, eucalyptus oil, the compound tincture of benzoin 
and creosote are indicated. Creosote can be employed by 
inhalation by means of a perforated zinc inhaler, the medica- 
ment being dropped upon a sponge placed in front of the 
inhaler and the following prescription can be used for this 
purpose : 

^ Menthol grs. v. (0.66) 

Alcohol ^ 

Creosote > aa 3iiss (10.00) 

Chloroform J 
HI Sig. Put 5 to 10 drops on the inhaler and inhale the 
vapor for half an hour to an hour or more. 

If the upper air passages are irritable and dry, some of 
the soothing inhalations or sprays may be used, composed 
of alkaline solutions, or menthol, eucalyptus, camphor or 
carbolic acid in liquid albolene or petroleum. The following 
is a local application for the pharynx: 

^ Iodin grs. ii-v (0.1-0.3) 

Potass, iodidi grs. xvi-xlviii (1.0-3.0) 

Glycerini 3iiss (10.0) 

1TL Sig. Apply every day or every second day. 

When the cough is persistent and harassing, far in excess 
of the result produced — the elimination of secretions — and 



142 PULMONARY TUBERCULOSIS 

is interfering with nutrition and rest, one will often be 
obliged to employ some sedative agent, although simple 
remedies should first be tried, such as demulcent drinks, as 
sea-moss, or flax-seed tea, acacia, lacturarium, gelatine, or 
some form of lozenge. Of the opium sedatives, codein, 
heroin and dionin are the least objectionable and can be ad- 
ministered in capsules, tablets or in solution, either alone or 
in combination with chloroform spirits or chloroform water, 
or aromatic spirits of ammonia. The doses are codein, grs. 
Ya to y 2 (0.01-0.03) ; heroin, grs. 1-24 to 1-12 (0.0025-0.005) ; 
dionin, grs. 1-6 to 1-2 (0.01-0.03). 

The following are some simple prescriptions containing 
the above : 

fy Heroin grs. ii (0.13) 

Spts. ammon. aromat. 3v (20.0) 

Aquae qs. ad. 5iv (120.0) 

TTL Sig. One teaspoonful in water three or four times a 
day. 

ty Dionin grs. v (0.2) 

Aq. amygd. amar. Siss (45-°) 

Aquae q.s. ad. Siii (9°-°) 

TTL Sig. One teaspoonful three or four times a day. 

^ Codeinae grs. viii-xvi (0.5-1.0) 

Syr. pruni virg. 
Aquae aa gii(6o.o) 

1TL Sig. One teaspoonful three or four times a day. 

^ Heroin grs. i-ij^ (0.06-0.09) 

Spts. chloroformi gii— giii (8.0-12.0) 

Aquae menth. pip. Siii (9°-°) 

TTt Sig. Teaspoonful three or four times a day. 

" Not until all hope of recovery has vanished," wisely re- 
marks Bonney, " should the comfort of the patient with dis- 
tressing cough be promoted by the free exhibition of mor- 
phine, heroin or codeine." 



TREATMENT OF SPECIAL SYMPTOMS 143 

Fever 

As with the cough, the main reliance for combatting this 
symptoms is out-of-door air and rest — absolute rest — as has 
been previously insisted upon. The patient may have to be 
kept at rest for weeks or months before the fever subsides, 
but so long as there is any hope of arresting the disease, the 
rest treatment must be maintained while the fever exists. 
The sleeping porch is the best place for the fever patient, but 
if this is unattainable, a well-ventilated room with open win- 
dows is the next best arrangement; in the latter case the 
patient may be carried out to a couch or reclining chair upon 
a piazza for a portion of the day if it can be done without dis- 
quieting him. 

The employment of antipyretic drugs should, as a rule, be 
avoided, as they have but a transitory and deceptive effect; 
the only one I ever employ is pyramidon 5 to 6 grs. (0.3- 
0.4 gms.) either given in the form of tablets or in solution. 
In the latter case the requisite dose is dissolved in a glass of 
water and slowly sipped during an hour. Taken from three 
to six hours before the expected rise of temperature, a single 
dose is usually sufficient for twenty-four hours. I have 
sometimes found that a few doses of this drug will render 
the patient free from fever for a considerable time, and this 
fever-free interval will enable him to . gain in weight and 
strength. Pyramidon can be used for a long time and ac- 
cording to Saugman the cases of fever in tuberculosis which 
are not favorably influenced by it are few. It must always 
be remembered, however, that the main reliance in the fever 
of tuberculosis is fresh air and rest. 

Night Sweats 

Genuine night sweats are profuse and cover the patient 
with moisture so that his night garments are saturated. 
They must be distinguished from the comparatively slight 
perspiration common to any weakened condition which is 
often called "night sweats" by the patient. The real night 
sweats are usually a concomitant of the fever and are the 



144 PULMONARY TUBERCULOSIS 

result of toxic absorption. Like the fever, the main treat- 
ment is fresh air and rest. The bed clothing should be of 
light weight and only enough to render the patient comfort- 
able. After the sweating has occurred the body should be 
rubbed dry and the night clothes changed. On retiring a 
glass of warm milk with one or two teaspoonfuls of brandy, 
as recommended by Brehmer, is often of aid, as is also bath- 
ing the body with cool water and vinegar or dilute acetic 
acid, which can also be done in the late afternoon. 

If the above general procedure does not avail, sympto- 
matic drug treatment may temporarily be indicated and the 
two remedies I have found most efficient are agaracin gr. 
i-io and camphoric acid grs. 30, given in powder an hour or 
two before bedtime. Instead of the simple camphoric acid, 
one can use the pyramidon acid camphorate 12 to 15 grs. 
(0.75-1.0) in powder or aqueous solution, and thus the one 
preparation is effective both for the fever and the night 
sweats. 

Hemoptysis 

This is one of the most alarming symptoms to the patient 
and his friends, for it is often the first real evidence that 
tuberculosis may exist; "the stoutest heart quails under it. ,, 
As a matter of fact it is never fatal in the early cases and 
rarely so in more advanced ones. It may, however, much 
weaken and discourage the patient and may lead to the 
development of broncho-pneumonia, — a very serious com- 
plication, or other acute symptoms. 

Most cases of hemorrhage would subside spontaneously 
without medicinal treatment if the physician and patient 
were content to trust nature, but almost invariably active 
treatment is demanded. If the hemorrhage is so slight as 
only to cause " streaked sputum," no treatment is indicated 
except to refrain from active exercise and keep in touch with 
the physician. When the hemorrhage is more than this, and 
active treatment is indicated or expected, the principle upon 
which one proceeds is that of lowering the blood pressure 
and thus favoring coagulation ; hence one should, if possible, 
at the first ascertain the blood pressure. 



TREATMENT OF SPECIAL SYMPTOMS 145 

The practical plan of procedure, modified, of course, by 
individual conditions, may be summarized as follows : 

(a) Absolute rest in a well-ventilated room, in a semi- 
recumbent position. As Dr. James Jackson sixty years ago 
wisely said: "Rest of body and mind and 'holding the 
tongue' are quite as important at the moment of bleeding 
as the medicinal articles. " 

(b) An ice bag to the chest and cracked ice by the mouth 
(more of a placebo than for any real effect). 

(c) Unless the blood pressure is abnormally low, the in- 
halations of the fumes of nitrite of amyl., using the glass 
pearls, or spirets containing three of five minims or more, or 
i-ioo gr. nitroglycerine, either subcutaneously or upon the 
tongue; later, the nitrite treatment may be continued, if 
necessary, by sodium nitrite gr. i, every three or four hours 
for a day or two. 

(d) Purgation by the use of one ounce of magnesium sul- 
phate, given twice, the first dose soon after the initial attack, 
and the second dose on the second day. 

(e) If the cough is annoying and frequent, small doses of 
codein or heroin, frequently repeated, *4 g r - oi the former 
and 1-12 to 1-6 gr. of the latter. One should be very cau- 
tious about giving morphin or continuing its use, although 
there may be occasions when one-eighth of a grain or even 
one-fourth may be indicated, given subcutaneously. The 
continued use of the morphin is not without danger, for it 
may favor the development of broncho-pneumonia. 

The diet should be liquid and cold for the first day or two, 
such as milk with an alkali, soups, ice-cream, gelatine prep- 
arations, wine-jelly, etc. The patient should be kept quiet 
in bed one week after all traces of blood have disappeared. 

Where the hemorrhage is severe and recurring, such as 
more frequently occurs in the latter stages of the disease, 
and the above means do not prove effective, there are other 
remedial measures which may be tried. Blood serum from 
the horse or rabbit has been employed with success; either 
fresh rabbit's blood serum in 15 c.c. doses subcutaneously, 
repeated at intervals of four hours or longer, can be used, 



14^ PULMONARY TUBERCULOSIS 

or the normal horse serum previously prepared, and now- 
furnished in vials or syringes. In cases where the hemor- 
rhage is recognized as coming from one lung, and there is 
little active disease in the other, artificial pneumothorax, 
when it can be employed, has proved effective, but its use 
presupposes a pleural cavity free from adhesions or suffi- 
ciently so to allow adequate compression of the lung. 

Other remedies are atropine sulphate 1-50 gr. subcutan- 
eously, and pituitary substance or extract, said to be of spe- 
cial value when the heart is very rapid and the respirations 
are increased. Chloride or lactate of calcium 10 to 20 grs. 
(0.6-1.2), or calcium sulphide 1 gr. (0.06) have been used 
with apparent success by some, but in my experience I have 
not found them of any great value. 

An old procedure is the application of ligatures to the 
extremities with a bandage of any kind, — a towel, sheet, or 
rubber tubing. First one thigh is constricted and then the 
other, and, if necessary, the arms in a similar manner. After 
half an hour, or an hour, the bandages may be removed, one 
at a time. Another old time remedy when nothing else is 
at hand is dry salt by the mouth, a nauseous dose. If the 
hemorrhage is so severe that the patient becomes exsanguin- 
ated, such remedies are indicated as in any case of great loss 
of blood, the infusion of physiological salt solution, and 
cardiac stimulants, such as aromatic spirits of ammonia, 
champagne, oxygen, etc. When the blood fills the bronchi 
and upper air passages, coughing and deep breathing should 
be encouraged in order to get rid of the effused blood. 

Pain 

Pain in the chest, a frequent symptom, must be treated 
according to the cause if it can be determined. If it is pleu- 
ritic, strapping the chest with adhesive plaster will generally 
give relief. When the cause is not evident, external appli- 
cations, such as a belladonna or mustard plaster, tincture of 
iodine, heat or an appropriate liniment may be employed. 
In other cases, aspirin or, exceptionally, a subcutaneous in- 
jection of codein or morphia may be required. Neuralgic 



TREATMENT OF SPECIAL SYMPTOMS 147 

or rheumatic pains and others of indefinite origin are to be 
treated by external applications and internal medication as 
the indications require. 

Insomnia 

If the cough keeps the patient awake, this must be appro- 
priately treated as indicated above, so also as regards night 
sweats. The best hypnotic is the open-air life and will gen- 
erally suffice. It occasionally happens, however, that a pa- 
tient cannot sleep well out of doors from nervousness or in- 
ability to keep warm, and under such circumstances it is bet- 
ter to sleep indoors ; but the bedroom should be quiet, well- 
ventilated and darkened, or else one should cover the eyes 
with a dark bandage. A quiet, restful evening, and a glass 
of warm milk or a light meal at bedtime will conduce to a 
good night's sleep. Care should be taken that the feet are 
warm, for one cannot sleep with cold feet. If any drug is 
considered necessary, I have found trionol 5 to 10 grains the 
most satisfactory one. 

Dyspnoea 

This is not frequently a distressing symptom in the ad- 
vanced stages of the disease, and when there is extensive 
fibroid infiltration, thus greatly reducing the respiratory 
capacity. The main indication is the restriction of the res- 
piratory demands, within the smallest compass possible, by 
rest. Temporary relief may be obtained by some of the 
diffusible stimulants, such as ammonia, Hoffman's anodyne, 
and oxygen ; strychnia and arsenic are also of value. When 
all else fails, opium in some form will be the last resort. 

Laryngeal Tuberculosis 

This complication is usually secondary to pulmonary tu- 
berculosis and when advanced it is a very distressing and 
grave one. The diagnosis of laryngeal tuberculosis is not 
easy: hoarseness and pain in a tuberculosis individual is 
strongly suggestive of it, but not proof, for other conditions 
may cause these symptoms, such as syphilis, and the dis- 



I48 PULMONARY TUBERCULOSIS 

ease may be present while the symptoms are absent. The 
characteristic local signs of a well-marked case are more or 
less infiltration of the laryngeal tissues with loss of tissue 
and ulceration. 

The general treatment is that of the pulmonary disease, 
the open-air regime and rest of the larynx, — absolute inter- 
diction of talking, whispering not even being allowed. Local 
treatment will depend upon the stage and character of the 
local condition; in mild cases little or no topical treatment is 
indicated. When direct applications are to be made to the 
larynx, it will generally be wiser to call in the aid of one 
skilled in doing this and, hence, only such local treatment 
will be mentioned as the general practitioner can readily 
apply. 

In the first place, the larynx must be kept clean with 
some alkaline spray, such as Dobell's solution, to which rose- 
water may be added, one drachm to the ounce, which may 
be followed by a spray of argyrol ten to twenty per cent, 
solution. When there is pain and much discomfort, a spray 
of the following will give relief, the patient inhaling while 
it is applied : 

Menthol grs. v (0.3) 

Liquid petroleum §i (30.0) 

Til Sig. Use in vaporizer. 

3 Menthol grs. iv (0.25) 

Olei eucalypti 

Olei gaultherise aa grs. xvi (1.0) 
Liquid petroleum §iii, 3ii (100.) 

irt Sig. Use in vaporizer. 

or simple liquid petroleum may be used. Medicated steam 
inhalations are also soothing. Lyon * recommends the fol- 
lowing : 

1 A Report of 241 Cases of Laryngeal Tuberculosis treated at the Rutland 
State Sanatorium (Mass.) — Boston Medical and Surgical Journal, July 2, 
1914. 



9 



TTL 



TREATMENT OF SPECIAL SYMPTOMS 149 

Tr. benzoin co. 3i (4.00) 

Eucalyptol 4 minims (0.25) 

Menthol 2 minims (0.12) 



When the epiglottis is involved and there is dysphagia, 
some local anaesthetic must be employed before eating, such 
as orthoform, anasthesin, a spray of two per cent, cocaine, or 
of heroin, three grains to the ounce. 

Much attention must be given to the feeding of the patient 
under these circumstances, else he well die of starvation. 
Small amounts of highly nutritious food, of a bland and 
semi-solid character, must be given, such as eggs, raw, 
minced meat, junket, milk and milk preparations, minced 
chicken, thick soups, wine jelly, etc. Butter, olive oil and 
cream should be employed as much as possible in the prep- 
aration of the various articles of food. 

There are many other local applications and procedures 
which can be employed in the different stages of laryngeal 
tuberculosis, but these are best left to the skilled laryngolo- 
gist. It is well to repeat, however, that the basis of treat- 
ment of this condition is complete rest of the larynx and the 
rigid execution of the open-air treatment. 

Cases of Hemorrhage 

I. M. R., aged 26, housewife. Family history: negative. 

Previous history: She had always been well and had 
suffered from no serious illness. Within the year, prior to 
consultation, she had had several hemorrhages of a few 
ounces each time, the last one ten days ago. On examina- 
tion there was moderate dullness at both apices, with harsh 
respiration and a few moist rales at the right supra-spinous 
fossa and also in the lower right axilla. According to her 
statement she had no cough or expectoration. At a sub- 
sequent examination, a month later, there were moist rales 
on cough throughout most of the right back. The sputum 
was negative. A little later she went to the Loomis Sana- 



150 PULMONARY TUBERCULOSIS 

torium, where she remained only about 3 months and re- 
turned against advice but much improved in physical signs 
and constitutional condition. Several months later she had 
two moderate hemorrhages and at intervals of months sev- 
eral others, but she always rallied well after them and they 
were followed by no acute symptoms. Finally she had a 
severe hemorrhage while on an automobile trip, and on her 
recovery from immediate effects she returned to the Loomis 
Sanatorium. A recent report says that the local symptoms 
are comparatively slight, and the general condition is satis- 
factory or improved. Sputum negative. 

This is a case of recurring hemorrhages with little, if any, 
appreciable influence for the worse upon the course of the 
disease. 

II. R. A., aged 24, shoe manufacturer. Family history: 
brother died of pulmonary tuberculosis, and the patient was 
with him during the last two months of his life. 

Previous history: always well. Present illness: has been 
feeling "run down" for several months and for the last two 
weeks has had a slight cough with expectoration. Several 
times recently he has had definite hemoptysis of several 
ounces and continues to have streaked sputum. He also 
has considerable afternoon temperature. 

On physical examination there is evidence of a lesion at 
the left apex, indicated by changes in the resonance and 
respiration and by the presence of moist rales on cough. 
The sputum was positive. The patient, being a Christian 
Scientist, could not be induced to take continued treatment 
in a sanatorium or elsewhere, and went on, now trying 
one thing, now another, now showing improvement and 
again relapses, with hemorrhages from time to time more 
or less severe, and finally died of his disease three years 
later. 

In this case the occurrence of the hemoptysis first brought 
the patient to the physician, and the examination showed 
that the hemorrhage was a symptom of a well-established 
active tuberculosis. 

III. L. S., aged 38, cap-maker. Family history: negative. 



TREATMENT OF SPECIAL SYMPTOMS I5 1 

Previous history: spit blood 14 and 10 years ago and again 
a few days ago. 

Present illness: complains of cough and expectoration 
with streaked sputum. He is well nourished and has lost 
no flesh; is following his occupation. The physical exami- 
nation is negative, as is the sputum. 

This case is illustrative of many in which there is a slight 
hemorrhage or only streaked sputum, with no or few other 
symptoms and no physical signs. No radical treatment is 
indicated but such patients should be kept under observa- 
tion. Of course it is possible that the blood may come 
from the mouth or upper respiratory tract. 

IV. J. L. R., aged 53, an active business man. Has al- 
ways been well with the exception of a hemorrhage 20 years 
ago, which was followed by no symptoms. Several days 
before he was seen he had a small hemoptysis accompanied 
with a moderate temperature for a few days. The physical 
examination was absolutely negative. He was advised to 
take a two months' vacation, which he did, and then returned 
to work. For the last eleven years he has been perfectly 
well, with no evidence of any pulmonary disease. 

Cases of hemorrhage like the above not infrequently oc- 
cur, in which the hemoptysis is the only symptom and which 
is followed by no other, or no departure from normal health 
in any respect. The treatment is " watchful waiting." The 
man undoubtedly had a small undiscoverable tuberculous 
focus which temporarily became active and then quickly 
subsided without producing any lasting toxic symptoms. 

V. A. S., aged 33, salesman. Family history: negative. 
Previous history : always well and no serious illness with the 
exception of influenza. 

Present illness : he has a chronic cough, he says, and pain 
in the chest, with some dyspnoea on exertion. He has no 
loss of weight or strength and is a healthy-looking, well- 
nourished man. He has recently spit up a little blood, 
which alarms him. On physical examination there are a 
few persistent rales at the left supraspinous fossa with slight 



152 PULMONARY TUBERCULOSIS 

increase of voice sounds and tactile fremitas at the left apex. 
The temperature was a degree or two above normal. 

This was evidently a comparatively early case of active 
pulmonary tuberculosis and the hemoptysis was one of the 
symptoms. In spite of the appearance of good health, im- 
mediate treatment is indicated and if taken the prognosis 
is favorable. It was the hemoptysis which first brought 
the man to the physician, as happens in so many cases. 



CHAPTER XI 
TUBERCULOSIS IN CHILDREN 

" In order to save a race that is threatened by an infectious disease, the 
best plan is to save the cocoon." Pasteur. 

" Tuberculosis of the adult is the end of the song begun at the cradle." 

Von Behring. 

There are certain peculiar difficulties in the diagnosis of 
tuberculosis in children which do not exist in adults. In 
the first place, active tuberculous disease of the lungs as met 
with in adults is infrequent, and, second, tuberculous bron- 
chial glands (vide plates 6 and 6a, p. 12) are much more 
frequent; therefore, in making an early diagnosis, we have 
to make it chiefly from the symptoms — the detection of the 
diseased bronchial glands — and by the tuberculin test and 
by the X-ray. If it is true, as is now generally held, that the 
majority of consumptives are infected when young, as Opie 
declared, from his investigations : "Almost all human 
beings are spontaneously Vaccinated' with tuberculosis be- 
fore they reach adult life." The importance of detecting 
the disease in childhood is at once apparent, for then is the 
golden opportunity of so regulating the child's life that the 
latent tuberculosis may never become active. 

Symptoms 

What are the suspicious symptoms? 

In general, they are those indicating a definite depression 
of health, such as loss of weight, or failure to gain in weight, 
anaemia, malnutrition, loss of appetite, lassitude, irritability, 
and sometimes a dry, hard cough and night sweats. There 
may be also an irregular rise of temperature. It is true 
that all or many of these symptoms may occur from other 

153 



154 PULMONARY TUBERCULOSIS 

causes and are not characteristic of tuberculosis, but 
they should always make one suspicious and prompt a 
thorough examination and continued observation. It is 
also true that tuberculosis may exist and yet there may be 
no evidence of serious disturbance of health or no marked 
constitutional symptoms, but in this case no treatment is 
required other than good hygiene, for the defensive resist- 
ance of the body is equal to the attack of the tuberculous 
infection. This is especially true in later childhood. If 
there is a family history of tuberculosis, or an active case 
in the child's family, this fact should make one all the more 
suspicious. 

Physical Signs 

The physical signs are also not characteristic. On in- 
spection the child may show evidence of anaemia and malnu- 
trition. On percussion there is nothing definite; there may 
be slight dullness at the apices or on one side or the other 
of the sternum at the level of the second intercostal space 
in front and in the interscapular region behind. Ausculta- 
tion is no more satisfactory. We have the D'Espine sign, 
often difficult to make out, of questionable value, and only 
to be obtained when the bronchial glands are of considerable 
size. It consists in the persistence of the bronchial whisper 
or bronchophony heard over the vertebrae below the level of 
the seventh cervical spine. When positive, it merely indi- 
cates the enlargement of the tracheo-bronchial glands, but 
tells us nothing as to the cause or nature of the enlargement. 
Another sign, when it can be determined, is diminished res- 
piration over one lobe, especially the right lower lobe. 

When all is said, however, percussion and auscultation 
give but little definite information unless there is lung infil- 
tration or consolidation. 

The X-Ray 

The X-ray is of especial value in determining the presence 
of enlarged bronchial glands, but the Roentgenographs must 
be carefully made and interpreted by one experienced in 



TUBERCULOSIS IN CHILDREN 155 

X-ray work. When the enlarged glands are present, the 
plate shows spots of shading along the right side of the 
vertebral column, and also along the hilu's. Here, again, 
it must be borne in mind that although the bronchial glands 
may be shown to be enlarged, the X-ray does not tell us 
whether they are actively tuberculous or not. 

The Tuberculin Test 

The von Pirquet cutaneous test is of the most value in 
diagnosis in children under five years of age. Of course, a 
positive reaction only indicates a tuberculous infection, but 
tells us nothing as to its activity. It is of greater signifi- 
cance when negative than when positive; but with other 
suggestive symptoms and signs a positive von Pirquet adds 
to the weight of evidence in favor of active glandular tuber- 
culosis. With older children, the subcutaneous tuberculin 
test may be used, the dose, of course, being proportionately 
smaller than with adults; for example, with children of 
eight or ten years of age, o.ooi to o.oi mg's of Koch's old 
tuberculin may be employed. 

The conditions under which this test should be made are 
the same as with an adult. The patient should be afebrile; 
the reaction phenomena are also the same. Used with care 
and in proper doses, the subcutaneous tuberculin test is quite 
safe. Holt declares that he has seen no unfavorable symp- 
toms from this form of the test even in the youngest infants. 

The Diagnosis 

In order, then, to make a definite or probable diagnosis of 
active bronchial gland tuberculosis, we must have enough 
or all of the following evidence : 

(a) Constitutional symptoms, such as weakness, undue 
fatigue, malnutrition, anaemia, fever, rapid pulse and a dry 
cough without any discoverable physical signs of disease. 

(b) A positive von Pirquet or subcutaneous tuberculin 
test. 

(c) A positive D'Espine sign. 

(d) X-ray evidence of enlarged bronchial glands. 



I56 PULMONARY TUBERCULOSIS 

Treatment 

When we have established the diagnosis, the child is to be 
placed under treatment, which is, in general, that of the open- 
air regime. The diet should be abundant and rich in fats 
and proteids. The child should sleep under open-air con- 
ditions. There should be rest periods during the day and 
over-fatigue should be avoided. If there is no fever, or other 
acute symptoms requiring complete rest, the child may for 
a part of the day attend an open-air school, where rest peri- 
ods and lunches are afforded. Drugs are not generally indi- 
cated except for especial symptoms ; if, for example, anaemia 
is present, iron or arsenic is indicated, such as the syrup of 
the iodide of iron or Fowler's solution. Tuberculin has been 
employed with varying opinions as to its value by those who 
have used it. Sunshine is important, and the child should be 
encouraged to rest and play in the sunshine. 

Pulmonary Tuberculosis 

When the child shows evident physical signs of pulmonary 
involvement, the diagnosis depends upon the interpretation 
of these signs, together with the evidence obtained from the 
symptoms, and when sputum can be obtained, upon the re- 
sult of its examination. We may have signs of a bronchitis 
or a consolidation which may or may not be of a tuberculous 
origin. If the child has been exposed to the infection in the 
family; if a chronic cough develops; or fever not evidently 
caused by other conditions; if consolidation is present and 
persists, particularly if it involves the middle lobe of the 
right lung anteriorly (Holt) the case is probably one of tu- 
berculosis. 

Slight or more marked physical signs must be interpreted 
very much as in the case of an adult, and be considered in 
connection with the symptoms. One does not so frequently 
hear rales in children as in adults, and the same physical 
signs in children are not always so significant of tubercu- 
losis as with adults. 



TUBERCULOSIS IN CHILDREN 157 

Treatment 

The treatment of children with active pulmonary tubercu- 
losis is practically the same as that for adults. If possible, 
the child should be sent to a sanatorium where the treat- 
ment, as a rule, can be more efficiently carried out. Out- 
door sleeping, rest, nutritious food and sunshine are the 
essentials. It is of the greatest importance that the young 
child should be protected from all sources of infection, 
whether from the milk or a tuberculous individual in the 
home, and, likewise, its strength should be carefully con- 
served during the convalescence from measles and whooping 
cough, which diseases render the child peculiarly susceptible 
to the tuberculous infection. Later in childhood, when re- 
sistance to tuberculous infection, or the extension of an 
already existing infection, is not well established, the child 
should be given such general care, in regard to fresh air, 
food, rest, bathing, etc., as will secure and maintain a high 
standard of health. 

The following "Diagnostic Standards" of Thoracic Tu- 
berculosis in Children of the National Tuberculosis Asso- 
ciation were prepared by the Diagnostic Standard Commit- 
tees of the " Framingham Community Health and Tubercu- 
losis Demonstration " : 

THE DIAGNOSIS OF THORACIC (PULMONARY, 

BRONCHIAL GLAND, ETC.) TUBERCULOSIS 

IN CHILDHOOD 

Definitions — Statements 
History 

i. History and Exposure: An occasional case of tubercu- 
losis in the patient's uncles, aunts, cousins, etc., should not 
be considered of importance, unless there has been intimate 
exposure and personal contact with such a case. It is an 
important fact, however, when the patient's immediate rela- 
tives, as mother, father, brother, sister, nurses, nursemaids, 
attendants, etc., have been tuberculous, and especially so 



I58 PULMONARY TUBERCULOSIS 

when there has been prolonged and intimate contact. Such 
prolonged exposure from human sources or from milk and 
milk products, especially under unhygienic habits or sur- 
roundings, is of great importance. This question should be 
gone into with the utmost care, particularly as regards occu- 
pational risks. 

2. Loss of Weight: By loss of weight should be under- 
stood an unexplainable loss of at least 5 per cent, below 
normal limits for that particular child, or an unexplainable 
failure to gain weight over a period of four months. 

3. Loss of Strength: By loss of strength in its pathological 
sense is meant ease of tire and lack of staying power which 
are unusual for that individual child and which cannot be 
satisfactorily explained. 

4. Cough: No cough is characteristic of tuberculosis in 
childhood. Persistent cough for six weeks requires investi- 
gation. Tuberculosis can and often does exist without any 
cough whatsoever. In certain cases of bronchial gland tu- 
berculosis there may be a brassy, strident, paroxysmal cough 
resembling that of pertussis. 

5. Hemorrhage: As in adults, any amount of blood, with 
or without sputum, requires medical investigation as to its 
source. This is a rare symptom in childhood. 

Examination 

1. Fever: In young children rectal temperatures alone are 
dependable. To constitute fever in its pathological sense in 
childhood there must be a more or less constant elevation of 
temperature over 100 degrees, taken at. various times dur- 
ing the day and lasting over a period of at least one week. 
In older children temperature rules for adults apply. 

2. Elevation of Pulse: No definite standards can be laid 
down as to what constitutes elevation of pulse, as this varies 
according to the age. Observation should be over a longer 
period and a wider latitude allowed than in adults before 
attaching significance to this as a symptom in childhood. 

3. Hoarseness: Any huskiness or persistent hoarseness 
requires investigation. This is likewise rare in childhood. 



TUBERCULOSIS IN CHILDREN 159 

4. Dullness. Only very light percussion should be used. 
Dullness is not to be looked for at the apices as in adults, but 
over both sides of the sternum (parasternal dulness) and 
between the scapulae (interscapular dulness). 

5. Rales: Rales are not to be regarded as essential in 
diagnosis and are not in themselves alone evidence of tuber- 
culosis. In fact by the time rales are found in pulmonary 
tuberculosis in childhood the disease is usually advanced and 
the diagnosis only too evident. 

6. Altered Voice and Breath Sounds: Pure bronchial 
breathing and egophony are comparatively rare in tubercu- 
losis in childhood. Harsh, prolonged, high pitched expira- 
tion and an intense whispered voice are often present. The 
whispered voice and not the spoken voice should be used. 

7. D'Espine's Sign: Intense whispered voice heard be- 
low the third dorsal vertebra is considered by many as ab- 
normal and indicates the presence of enlarged bronchial 
glands. Such glands are not necessarily tuberculous, how- 
ever. 

8. Sputum: Sputum, if present, should be examined. It 
is comparatively rare in tuberculosis in childhood. 

Minimum Standards 

On the basis of these definitions the following minimum 
standards in the diagnosis of active tuberculosis in childhood 
have been formulated : 

1. Given a definite history of exposure, either from 
bovine or human sources, any symptoms, constitutional or 
local, require the most careful investigation, although they 
may not necessarily be due to tuberculosis. 

2. Constitutional signs and symptoms of disease, such 
as loss of weight and strength, fever, etc., are of more im- 
portance than signs and symptoms relating to the chest. 

3. Other causes for constitutional signs and symptoms, 
such as diseased tonsils or adenoids, carious teeth, improper 
feeding, rickets, etc., should be investigated before these 
signs and symptoms are attributed to tuberculosis. 



l6o PULMONARY TUBERCULOSIS 

4. There may be extensive signs in the lungs, such as 
dullness, rales, altered voice and breath sounds, without 
these being due to tuberculosis. On the other hand, active 
tuberculosis may be present without definite signs and 
symptoms in the lungs. 

5. The presence of tuberculosis elsewhere in the body, 
such as glands, bones, joints, etc., is not necessarily indica- 
tive of tuberculosis in the chest, nor is it true that these 
forms of tuberculosis convey immunity against pulmonary 
disease. 

6. Tuberculin Tests. The Von Pirquet skin test is the 
best to use. When this test, properly applied, has been, 
repeatedly negative on three trials, except during or after 
an attack of measles, or in the presence of far advanced tu- 
berculous disease, tuberculosis may be ruled out. A posi- 
tive skin test in children under five years of age may be in- 
dicative of tuberculous disease, and points to the necessity 
for further observation. The diagnostic value of a positive 
tuberculin test becomes progressively less important, as 
significant of active disease rather than infection, in the 
years from five to fourteen. 

7. A definite history of exposure, with a positive tuber- 
culin reaction, accompanied by constitutional signs and 
symptoms, establishes a diagnosis of tuberculosis, even if 
the signs in the chest are vague, indefinite or absent. A 
similar history of exposure, even with a positive tuberculin 
reaction, but without constitutional signs and symptoms and 
without definite signs in the chest, does not justify a diag- 
nosis of tuberculous disease, but merely of tuberculous in- 
fection, except possibly in very young children. 

8. The X-ray may give valuable confirmatory evidence. 
A definite diagnosis of tuberculosis is not justified on X-ray 
examination alone. In every case the interpretation of the 
X-ray plate should be made by one qualified to decide in 
such matters. 

9. In all cases in which there is doubt, it is better to make 
a provisional diagnosis of tuberculosis and to give the child 
the benefit of hygienic measures and prolonged observation, 



TUBERCULOSIS IN CHILDREN 



161 



although this need not necessarily mean that the child be 
sent to a sanatorium or hospital or be definitely stamped 
as a consumptive. 

10. Finally, a correct diagnosis can be reached only by 
means of common sense and a careful consideration of a 
multiplicity of minor signs and symptoms, local and con- 
stitutional. 

Cases of Tuberculosis in Children 
Case I. 

M. S., Female, age 7 years. 

Family history : Father died of tuberculosis 3 years ago. 
Mother has tuberculosis. 

Past History: Whooping cough and pneumonia 3 years 
ago. Scarlet fever 1 year ago. 

Present illness : Has always had more or less cough. 
Has not been so well since scarlet fever. 

Physical examination: Right lung slight dullness to third 
rib and to the sixth dorsal spine in the back. D'Espine sign 
moderately well marked to third dorsal spine. 

Case II. 

G. K., Female, age 6 years. 

Family history: Father had tuberculosis 11 years ago, 
now arrested. Mother well. One sister had tuberculosis, 
apparently arrested. One sister died, at 9 months, of tuber- 
culous meningitis. Another sister died, at 3^ years, of 
vertebral tuberculosis. 

Past history: Whooping cough at 6 months. 

Present illness : More or less cough since whooping 
cough, with occasional slight rise of temperature. 

Physical examination: Right lung slight dullness to sec- 
ond rib in front and to third dorsal spine in back. Left lung 
slight dullness to third rib in front and to the third dorsal 
spine in back. 

In both of the above cases the diagnosis could not, with 
certainty, be made from the physical signs alone, and which 
is so frequently the case with children, but with the family 



1 62 PULMONARY TUBERCULOSIS 

history, the lasting cough and other evidence of constitu- 
tional symptoms of active disease, the diagnosis was estab- 
lished and sanatorium treatment instituted with favorable 
results. 

Case III. 

A. B., Female, age 9 years. 

Family history: Father died of tuberculosis and while 
suffering from the disease he had been in the habit of fond- 
ling and kissing his children. 

Past history: Had a severe cough with slight expectora- 
tion for a considerable time. Six weeks previous to her 
examination she had been operated on for enlarged tonsils 
and adenoids, but with no effect upon the cough. 

Present illness : A nervous irritable child, with cough. 
She was not inclined to play but would lie about the house. 
She would rarely go out with other children, and if she did 
she would soon return to lie down and rest. At frequent 
intervals for a few days at a time she would have a rise of 
temperature ranging up to ioo°. She had raised a little 
blood two or three weeks previously. Her appetite was 
poor. 

The physical examination showed nothing abnormal ex- 
cept a slight dullness at the left apex. 

The diagnosis of active tuberculosis was made upon the 
family history and the marked symptoms, and admission to 
the sanatorium advised. 

Constitutional symptoms, even without local signs, are a 
more trustworthy guide in making a probable diagnosis of 
active tuberculosis in children and in instituting treatment 
than physical signs without constitutional symptoms. In 
the latter case no treatment is indicated, for the child is not 
ill. 

Case IV. 

E. K., male, aged 13 years. 

Family history: Mother died of tuberculosis. 

Past history: Measles. 

Present illness: Began two years ago with cold. Dur- 



TUBERCULOSIS IN CHILDREN 163 

ing the past two winters had cough with some sputum, both 
disappearing during the summer. Has occasional pain in 
chest — tires easily — gets out of breath quickly — has had a 
few chills and night sweats. Temperature and pulse are 
normal at present but has had occasional attacks of fever. 
His highest weight has been 91. Weighs 84% now. 

Physical examination : Fairly well developed — fairly well 
nourished. Right lung shows dullness throughout front 
and back. A few rales at base posterior. Left lung nega- 
tive. Teeth are poor. Other organs apparently normal. 

Case V. 

M. S., female, aged 8. 

Family history. Nothing important. 

Past history: Tonsillectomy at 4 years. 

Present illness: Began two years ago with cough — no 
sputum. Has some pain in chest at times. At play she 
tires easily and is short of breath. Her appetite is variable. 
Has had a few chills (but no night sweats). Is occasionally 
hoarse. Has spit blood once. Afternoon temperature 
varies from normal to 99.6 — pulse 90 to 100. Her highest 
weight has been 60 lbs. At present net weight is 49%. 

Physical examination: Child fairly well developed — 
poorly nourished. Right lung — dullness to third rib in front 
and to sixth dorsal vertebra in back. Slight whispered voice 
over apex front and back. Left lung — slight dullness to 
third dorsal vertebra in back. Other organs apparently 
normal. 



CHAPTER XII 

CLIMATE IN THE TREATMENT OF TUBER- 
CULOSIS 

" The glorious sun 

Stays in his course and plays the alchemist; 
Turning, with splendor of his precious eye, 
The meagre cloddy .earth to glittering gold." 

King John, Act III, Sc. I. 

" Soon as a man finds himself spitting and hacking on rising in the morn- 
ing, he should immediately take possession of a cow and go high up into the 
mountains and live on the fruit of that cow." 

Celsus. 

Before considering the uses of climate in the treatment of 
pulmonary tuberculosis, it will be well to get a clear idea 
of what we mean when we speak of climate. The climate 
of any locality is its average weather conditions, and by 
weather we mean all those atmospheric elements which are 
noticed by sight, feeling, or observed by instruments; and 
these include the temperature, humidity, wind, the condi- 
tion of the sky, as to cloudiness or sunshine, and the occur- 
rence of precipitation as rain or snow. By the term weather, 
we mean these conditions as observed at a particular time or 
during a short period, while by climate, we mean the aggre- 
gate of weather conditions extending over a longer period. 
The average value of these conditions of any region consti- 
tutes its climate ; for example, we say that the winter climate 
of northern New England is cold with a considerable precipi- 
tation in the form of snow, and much cloudiness, but the 
weather of a single winter may be comparatively mild with 
little snow and much sunshine. 

In estimating the climate of any region one must know 
the average range of the various climatic elements: (a) the 
average or normal temperature, its daily range, and the ex- 
tremes of heat and cold; (b) the humidity, estimated as the 

164 



CLIMATE IN THE TREATMENT OF TUBERCULOSIS 



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1 66 PULMONARY TUBERCULOSIS 

average relative humidity; (c) the precipitation in inches; 
(d) the wind, its velocity and prevailing direction; (e) the 
number of clear, fair, and cloudy days. The latitude and 
longitude of the locality should also be known. Such data 
for a large number of resorts are now available from govern- 
ment weather bureaus ; the climatic chart of New York will 
serve as an illustration. (Fig. 21.) 

Since such favorable results have been obtained in any 
and all climates in the treatment of tuberculosis by the skill- 
ful application of the open-air regime, the role of climate 
does not now occupy the paramount place it once did. For- 
merly a change to a more favorable climate was considered 
the most essential factor in the treatment, and when once 
the patient had reached the climatic El Dorado, he was left to 
himself to follow his ordinary or an extraordinary mode of 
life with but little, if any, medical oversight. A few re- 
covered and more died under this go-as-you-please plan. 

Experience has demonstrated, however, that the open-air 
treatment can be successfully carried out anywhere, even 
in the crowded city; for more depends upon the method, the 
careful attention to details, the skilled medical supervision, 
and the complete fulfillment of the out-door life than upon 
any especial climate. Nevertheless, it is obvious that, with 
an efficient hygienic-dietetic method, favorable climatic con- 
ditions are an added advantage. The purer the air the more 
favorable the other climatic conditions, the more perfectly 
the open-air treatment can be effected. Other things being 
equal, we therefore may desire to send the consumptive pa- 
tient to that locality where he will obtain the pure air and 
as many as possible of the other climatic excellencies, with 
the purpose of more perfectly following out the out-door 
life. 

The Favorable Climate 

The essential favorable climatic conditions for pulmonary 
tuberculosis are: (a) pure air free from bacterial impurities 
and dust; (b) the maximum amount of sunshine — good 
weather; (c) absence of or protection from high winds; (d) 



CLIMATE IN THE TREATMENT OF TUBERCULOSIS 167 

moderate dryness and more or less equability; (e) a medium 
or cool average temperature. 

Altitude, as in mountain climates, has been regarded as 
an element of much value in its influence upon tuberculosis, 
and most excellent results have been obtained in the high 
altitudes, such as at the Colorado and New Mexico resorts. 
The advantage of altitude is in the greater purity of the air, 
the greater number of clear and bright days, the intense in- 
solation under low atmospheric temperatures, and the gen- 
eral stimulating effect upon metabolism. Whether or not 
the lessened barometric pressure exercises any specilc influ- 
ence is doubtful; it increases the respiratory and cardiac 
function, which in certain cases may be of value. 

Good weather, bright sunny days, is an obviously desirable 
climatic condition, for it affords a better opportunity for the 
out-door life and under more comfortable and cheerful con- 
ditions. 

As to temperature, experience has shown that the tuber- 
culous individual makes greater gain in a medium or cool 
temperature, in the winter than in the summer. 

Dryness of the air is considered another important factor 
on account of its anti-catarrhal effect. With a dry climate, 
however, we have less equability of temperature, and the 
lower the relative humidity, the greater the daily range of 
temperature; thus, for example, the climate of Egypt is a 
very dry one, but the difference between the day and night 
temperature is from 20 to 30 degrees. Equability, however, 
except in the case of elderly or feeble persons, is not an im- 
portant factor. Wind is only harmful when the patient is 
directly exposed to it. On the other hand, when he is pro- 
tected from it, its influence is beneficial in purifying the air. 

Dr. Knopf thus briefly and admirably gives the character- 
istics of a favorable climate. He says : " The ideal climate 
for the average pulmonary patient, in the earlier and more 
hopeful stages of the disease, is the one where extremes of 
temperature are not great, with the purest atmosphere, 
relatively little humidity, much sunshine, and all conditions 
which permit the patient to live comfortably out of doors 



1 68 PULMONARY TUBERCULOSIS 

the largest number of days out of the year, and the largest 
number of hours out of the twenty-four." 

Beneficial Effects of a Favorable Climate 
In the first place, a favorable climate, such as has been 
indicated above, permits one to pursue the open-air life more 
completely and comfortably than in an unfavorable one. 
Second: It exercises a favorable influence upon tissue 
change, producing increased metabolism, improved nutrition, 
and a general stimulation of the vital processes. Third: It 
often favorably influences the mental attitude. One is more 
cheerful and hopeful in continuous pleasant weather and 
under sunny skies. Out-door life is more attractive when 
every day is a pleasant one; if one is able to take exercise, 
he can do so with greater ease and with a larger choice of 
out-door amusements. Again, complications, such as bron- 
chitis, laryngitis, penumonia, pleurisy, etc., are less likely to 
occur in a favorable climate than in such weather conditions 
as usually obtain, for example, in the northeastern portion 
of this country, not far from the Atlantic coast. The appli- 
cation of sunshine or heliotherapy has, of late years, through 
the influence of Rollier, of Leysin, Switzerland, been em- 
ployed with apparent success in certain forms of tubercu- 
losis, more especially in surgical forms with children, and so 
far as the evidence goes it seems also to be of value in pul- 
monary tuberculosis in adults. In order to most success- 
fully carry out this treatment, a sunny climate is obviously 
necessary. Vide "Heliotherapy" in Wood's Handbook of 
Medical Sciences. 

As to the influence of a change of climate upon the local 
condition, experience has shown that it is often greatly bene- 
fited; there is a diminution of the cough and a lessening of 
the expectoration. In brief, although a change of climate 
does not exercise any specific effect, yet, if rightly selected, 
it may be expected to improve the general condition, as to 
appetite, nutrition, etc., and diminish local activity. 

However valuable a factor a favorable climate may be, it 
must always be borne in mind that it is only a part of the 
general treatment and that not the most important one. Of 



CLIMATE IN THE TREATMENT OF TUBERCULOSIS 169 

first importance is proper hygiene, diet, and discipline, and 
skilled medical supervision. Without these the most favor- 
able climatic conditions will prove elusive. 

When is a Change of Climate Desirable 

A change of climate may be desirable for many reasons: 
the prominent one is that it may increase the patient's chance 
of recovery. He may not be doing well where he is, and 
the climate of his present locality may be a particularly un- 
favorable one. The environment of the patient may be such, 
as to family, or social conditions, that a change is advisable. 
The temperament of the patient may be such that change of 
scene and new surroundings will conduce to a more favorable 
mental attitude. Proper control of the patient may not be 
possible where he is. Age, sex and complicating diseases 
are other reasons which may render desirable a change. 
The financial condition of the patient is, of course, a deter- 
mining factor in making any change, unless one goes to a 
state or charitable sanatorium. It is better to make the best 
of home conditions than to go to a more favorable climate 
and suffer deprivations. As Trask well says (Public Health 
Reports 1917, 32-318) "Leaving home, except to go to a 
sanatorium, is fraught with much danger, unless one is 
financially able to meet all possible demands, and it should 
he most carefully considered even then." 

When a change of climate is under consideration, the first 
point to be decided is whether the general and local con- 
dition is such that any change will be beneficial ; and, second, 
the particular climate and resort most favorable for the in- 
dividual case. Furthermore, one must determine whether 
the patient should go to an "open" resort in the selected 
climate or enter a sanatorium there. 

Having decided upon the climatic resort, some knowledge 
of the local conditions should be obtained, such as its sani- 
tation, facilities for comfortable living, and the presence of 
a reliable physician to whom the patient can be referred. 
Opportunities for amusements and religious observances are 
an important consideration for some patients. 



I70 PULMONARY TUBERCULOSIS 

Cases Suitable for a Change of Climate 

The class of cases most suitable for, and most likely to be 
benefited by, a change of climate are : 

(a) Early cases with slight local involvement and little or 
no constitutional disturbance. 

(b) Further advanced cases in the quiescent state with no 
serious constitutional disturbance. These two classes of 
cases do well in the elevated regions, as in Colorado or New 
Mexico. 

(c) Advanced cases with little general disturbance and 
a moderate degree of resistance. A dry, moderately warm 
climate in regions of little or no elevation, such as southern 
California or the pine belt of the South, is most suitable for 
such cases. 

(d) Cases of cavities, if not extensive and in which the 
disease is quiescent, may be sent to the altitudes or the low- 
land regions. 

(e) Cases more or less advanced in which softening and 
excavation are going on, accompanied with much cough and 
expectoration, and with more or less constitutional disturb- 
ance ; if they can be comfortably transported, they may have 
their life prolonged and live more comfortably in a moder- 
ately warm, dry region, such as southern California or the 
southern pine belt; indeed, a quiescent condition of the dis- 
ease may be established. 

With regard to tuberculosis complicated with other dis- 
eases, such as kidney, liver or cardiac diseases, or diabetes, 
each patient must be individually considered. A climate 
that is favorable for the tuberculosis may be unsuitable for 
the complicating disease. 

In contemplating a change of climate for any case of pul- 
monary tuberculosis, we have to consider, on the one hand, 
the physical condition of the patient, both constitutional 
and local, and his economic and social circumstances; and, 
on the other hand, the climatic characteristics of the pro- 
posed resort, its general topography, its social environment, 
and the opportunity of obtaining competent medical super- 



CLIMATE IN THE TREATMENT OF TUBERCULOSIS I7I 

vision. Only thus can one expect to obtain successful re- 
sults from a change of climate. 

Not all cases are suitable to be sent away at all, and this 
is always the first question to be settled when a change is 
under discussion. Rarely should a patient be sent far away 
who is suffering from acute symptoms, such as fever, etc. ; 
nor should far-advanced, hopeless cases, as many have done 
and died far away from home. Others of little persistence 
and self-control, and who cannot be depended upon to carry 
out the plan of treatment, if sent away at all should go to a 
sanatorium where they can be under discipline. 

Favorable Climates for Pulmonary Tuberculosis 

The climates which have been found by experience to be 
favorable for tuberculosis in its curable stage are : (a) the 
high altitudes, as Denver, Colorado Springs and Estes Park 
in Colorado, all about 6000 feet high; Silver City (5800 
feet), Albuquerque (5000 feet), and Fort Bayard (4450 feet) 
in New Mexico. 

(b) The medium altitudes, as Saranac Lake in the Adiron- 
dack Mountains (1600 feet); Liberty, N. Y. (2300 feet) : 
Asheville, N. C. (2250 feet), in nearly all of which resorts 
there are good sanatoria. Many other eligible climatic re- 
gions can also be found in the White Mountains, the Berk- 
shires, Massachusetts, Vermont, Pennsylvania and northern 
New York. In the southwestern and Rocky Mountain re- 
gion of the United States there are many resorts of medium 
altitude, such as Las Cruces, New Mexico (3800 feet) ; 
Phoenix, Arizona (1100 feet); and Tucson (2400 feet). In 
southern California, sixty or more miles inland, there are 
various places with a mild, dry, sunny climate, such as Red- 
lands (1350 feet), Riverside (800 feet) and the Ojai Valley 
(900 to 1200 feet). 

(c) Of the sea-level resorts, there are many places in the 
dry southern pine belt with a mild sunny winter climate, 
such as Aiken, S. C. ; Summerville, S. C. ; Augusta, Ga., and 
others in North and South Carolina, Georgia and the interior 
of Florida. On the coast of southern California, there are 



172 PULMONARY TUBERCULOSIS 

San Diego, Los Angeles, Santa Barbara, Pasadena, and 
others with an eligible climate, both winter and summer. 

The climatic resorts that have been mentioned are but a 
few of the many in different parts of the country which offer 
favorable conditions for pulmonary tuberculosis and which 
fulfill the essential climatic conditions, viz. : pure air free 
from dust, sunshine, protection from high winds, an average 
cool temperature, and moderate dryness. 

In regard to the high altitudes, there are certain contrain- 
dications which should be mentioned; they are: (1) advanced 
age; (2) too great involvement or softening in both lungs; 
(3) cases complicated with kidney or heart disease, diabetes, 
asthma, or emphysema; (4) extensive fibroid infiltration 
with dyspnoea; (5) cases in which there is great irritability 
of the nervous system ; (6) advanced tuberculous laryngitis. 

Dettweiler thus well sums up the advantages and limita- 
tions of climate in the treatment of tuberculosis : "A speci- 
fic or truly immune climate does not exist. The value of a 
climate depends upon how perfectly it can aid in the pro- 
duction of improved nutrition and the restoration of all func- 
tions to a normal physiological standard, working through 
the body and mind to accomplish this. Tuberculosis can be 
cured in every climate where extremes do not exist. The 
individual condition of the patient alone determines the 
choice. To accomplish a cure the plan of treatment and the 
method of life the patient follows hold the first considera- 
tion." 



CHAPTER XIII 
PROPHYLAXIS 

" Prevention is better than cure, and far cheaper." 

John Locke. 

There are three main lines of effort in the prevention of 
tuberculosis: First, the protection of the infant and child 
from a tuberculous infection whether from within (in the 
home) or without. Second, the prevention of infection in 
the adult from one suffering from active tuberculosis. 
Third, the prevention of an active tuberculosis from a latent 
tuberculous focus, either in the child or adult. 

The Infection of the Child 

It is generally conceded that tuberculous infection occurs 
in childhood, and the occurrence of the positive von Pirquet 
reaction, almost without exception, in children over five 
years of age would appear to prove this. How do these 
children become infected? Either through association with 
some one in the household who is suffering from open tuber- 
culosis, as mother, father, brother, sister, nurse or an inti- 
mate friend; or through infection brought in from the out- 
side by means of the clothing, shoes, pet animals, etc., or 
through contamination of the nursery floor or wherever the 
child creeps or plays. In a certain number of cases gland 
and bone tuberculosis is caused by the bovine tubercle bacil- 
lus in milk. 

The Protection of the Child 

There may be a known case of open tuberculosis in the 
home or it may be undiscovered; consequently, any sus- 
picious symptoms, such as cough, loss of strength, debility, 
etc., occurring in the mother, nurse or attendant, or any other 

173 



174 PULMONARY TUBERCULOSIS 

member of the family, should at once be investigated. No 
nurse or attendant should be allowed to take charge of an 
infant or young child without a previous examination of the 
lungs. If the mother has open tuberculosis, the isolation of 
the child is the only safe course. When this is impossible, 
the infant should not be nursed by its mother, and she should 
take every precaution to avoid infecting her child. She 
should not fondle or kiss it, and should always hold some- 
thing before her mouth when coughing, and avoid coughing 
in the vicinity of the child. If the father or any other mem- 
ber of the family has tuberculosis, it is easier to keep them 
out of the way of the child. 

If the mother is known to have had tuberculosis before 
the birth of her child, the child is, as we know, not born tu- 
berculous, but may inherit a special susceptibility to the dis- 
ease; hence, especial attention should be given to increasing 
its resistance by general good hygiene. Care in feeding, 
open-air exposure, cool sponging, etc. Particular care 
should be taken to protect the child from the exanthematous 
diseases, whooping cough, diphtheria and tonsilitis, and if it 
contracts any of them, the convalescence should be carefully 
guarded. In artificial feeding, the milk should either be ob- 
tained from tuberculin tested cows or be pasteurized, and 
this is done by heating the milk in an Arnold's pasteurizer, 
or a home-made one of similar construction, to 145 F. for at 
least twenty minutes and then cooling it rapidly. As the 
child grows older, all hygienic measures should be taken to 
strengthen it, as has been indicated in Chapter X. When a 
case of tuberculosis exists in the family, every child should 
at once receive a careful examination. 

Prophylactic Measures in the Case of an Adult Suffering 
from Pulmonary Tuberculosis 

In the case of an adult tuberculous person at home, the 
physician must see to it that he has careful and detailed in- 
structions as to the safe disposal of his sputum and the safe- 
guarding of the family, and subsequently watch must be kept 
to see that the instructions are rigorously carried out. In 



PROPHYLAXIS 175 

the house the ordinary paper sputum receptacle is conven- 
ient, which can be burned with its contents; abroad, pieces 
of gauze or Japanese paper, folded several times, can be used 
and then put in an impervious paper bag, which is subse- 
quently burned. Such an arrangement is less conspicuous 
than a pocket spit cup. The use of the common handker- 
chief is obviously dangerous. In coughing, one should not 
do so in the presence of others, and should hold a piece of 
cloth or paper handkerchief before his mouth. The mouth 
should be cleaned frequently, at least before meals, with 
some alkaline solution, and the teeth brushed before and 
after meals. The hands should also be washed before eating. 

A beard or mustache is not desirable, for it may collect 
particles of sputum. The patient should not handle articles 
used by children or others, or leave articles about which may 
be handled. If all the dishes used at the table are washed 
in boiling water, it does not seem to me necessary for the 
patient to have his own separate set, as is often recom- 
mended, and to do so makes an unpleasant distinction. It 
is to be borne in mind, as Baldwin truly says, that "the care- 
ful, cleanly consumptive has a right to associate with other 
people in the ordinary pursuits of business and pleasure." 
On the other hand, every consumptive has an obligation to 
"protect his fellow human beings so far as possible from the 
disease." The patient should sleep by himself, and, if possi- 
ble, in a separate room. 

A "clean" consumptive is commonly said to be a "safe" 
one, and this is measurably true, as sanatorium experience 
has shown; but man is fallible, and with the best intentions 
and care a slip may occur in some way or other. Therefore, 
in a family where there are children, if there is a case of 
tuberculosis, the safest plan is to remove the consumptive 
to a sanatorium or elsewhere. 

Tuberculosis in the Workshop 

In the workshop or factory, or wherever many persons are 
brought together in close contact, it occasionally happens 
that there is present a case of active tuberculosis, and yet 



I76 PULMONARY TUBERCULOSIS 

the individual is able or feels compelled to work. This, 
however, happens less frequently at the present time on ac- 
count of the medical supervision and welfare work now car- 
ried on in many of the large industrial establishments, and 
the provision made for the consumptive workman when he 
is discovered. When it does occur, the consumptive work- 
man should be instructed in the ordinary precautions to be 
taken in coughing and expectorating. 

The Prevention of Active Tuberculosis from a Latent 

Infection 

As the von Pirquet test has shown, almost every one in 
thickly settled communities has received a tuberculous in- 
fection some time during their childhood. This infection, 
we believe, gives one more or less of an immunity from a 
subsequent exposure, although how permanent and com- 
plete this immunity is we cannot say. To avoid the possi- 
bility of a new infection, therefore, one should shun the im- 
mediate environment of a careless, unclean consumptive, or 
see that he is made a "safe" one by taking the precautions 
previously mentioned. In the second place one should so 
regulate his life as to maintain the normal condition of health 
and resistance to disease so that the latent childhood infec- 
tion may never become active disease. Regularity in one's 
habits, temperance, the avoidance of excesses, proper and 
regular meals, sufficient rest, exercise in the open air, open- 
air sleeping, good ventilation in workshop, office and the 
home, the avoidance of over-fatigue are the means every 
one should employ to live happily, healthfully, and to avoid 
active tuberculosis. 

Dusty Occupations 

As is well known, the mortality from pulmonary tubercu- 
losis is high in the dusty trades, such as steel grinding, the 
use of emery wheels, stone cutting, pottery, cotton, tobacco 
and shoe manufacture. To prevent the inhalation of the 
irritating dust, appliances should be provided for the removal 
of the dust, such as hoods connected with fans or respirators 



PROPHYLAXIS 177 

should be worn. The laws of many states now require some 
provision for removing the dust in the various grinding proc- 
esses, and thus shielding the workman from the injurious 
influence of the metallic or mineral particles. 

Disinfection 

When a room or apartment has been occupied by a con- 
sumptive, it is the physician's duty to see that it has been 
thoroughly cleaned and renovated before occupancy again. 
Fumigation does some good, but a thorough cleaning and 
renovating of paper and paint, and exposure to sunlight and 
daylight, is far more effective. Everything that has been 
used by the patient should be subjected to steam disinfection 
or destroyed. 

The Physician's Duty in the Prevention of Tuberculosis 

The physician from his intimate relation with so many 
households has an exceptional opportunity, and hence a 
definite obligation, to disseminate knowledge with regard to 
the prevention of tuberculosis in the community where he 
practices his profession. He can impress upon the consump- 
tive who is under his care the vital importance of preventing 
the spread of his disease to those about him through a proper 
and safe disposal of the sputum. He can seek by every 
means in his power to make an early diagnosis and institute 
timely treatment. He can see that the public of his partic- 
ular community is informed of the causes of the disease, and 
the part each person can do in protecting himself and others 
from the infection ; and that it understands the way in which 
infection takes place and how it may "become inoperative 
and powerless for harm." To do this is both the privilege 
and obligation of the physician, for at the present day the 
conscientious physician must regard the prevention of dis- 
ease as one of his sacred duties. 

The Framingham Tuberculosis Demonstration 

This demonstration was undertaken to determine the 
amount of active tuberculosis existing in a typical industrial 



I78 PULMONARY TUBERCULOSIS 

community, and the most effective practical procedure for its 
control. To accomplish the first object, namely, to deter- 
mine the actual prevalence of tuberculosis, recourse was 
had to medical examination drives, visiting all homes where 
the inmates were willing to be examined; to the organiza- 
tion of a tuberculosis consultation service, and to the estab- 
lishment of infant, school, industrial and other clinics. In 
the control of the disease the most important and effective 
means was considered to be early detection and hygienic 
care of those affected with the disease. 

It was found that there were something like nine active 
cases to one reported death, and many more cases were dis- 
covered than had been reported. At the end of nearly three 
years of the demonstration 200 cases were under observation 
as compared with 27 at the beginning. During the first year 
42 per cent, of the new reported cases were of an advanced 
type, while in the second year only 16 per cent, of the cases 
were advanced. 

Incident to the main object of the demonstration, that of 
discovering and controlling tuberculosis, much valuable gen- 
eral health work was done and sanitary surveys in the study 
of schools, factories and municipal health conditions made, 
as indirectly bearing upon the spread and development of 
tuberculosis. The most important contribution made by the 
demonstration was considered to be the medical consultation 
service as "the most promising means yet devised for secur- 
ing a reasonably complete knowledge of the amount of tu- 
berculosis existing in a given community." A tuberculosis 
expert of large experience was constantly employed for this 
service. Such a consultation service was particularly valu- 
able in detecting early cases in co-operation with the local 
physicians. 

This demonstration is well worthy of study as a model for 
other communities, and the same plan can, in its essential 
features, be followed anywhere. 

For the control of tuberculosis in any community one must 
know of the existing cases, which can be done by a thorough 
survey, by tuberculosis clinics, and by efficient school inspec- 



PROPHYLAXIS 1 79 

tion. Again, one must discover the disease at the begin- 
ning, make an early diagnosis, when treatment is most effec- 
tive. The demonstration has, moreover, shown the value 
of the consultation service, and this fact is being generally 
recognized and acted upon by other communities. 

At the present day preventive medicine is recognized as 
an essential part of the training and of the duty of the phy- 
sicians, and the control of tuberculosis will always constitute 
one of the most important sections of such preventive work. 
The study, therefore, of a great experiment in preventive 
medicine as applied to the control of tuberculosis, like the 
Framingham Demonstration, will be of great value and 
profit both to the medical student and the physician. 



CHAPTER XIV 
AFTERCARE AND MARRIAGE 

" Keep what you have." Plautus. 

" Oh yet we trust that somehow good 
Will be the final goal of ill. 
To pangs of nature, sins of will, 
Defects of doubt and taints of blood." 

In Memoriam. Tennyson. 

Aftercare 

It is now generally conceded that sanatorium treatment, 
and, indeed, the open-air treatment anywhere for a limited 
period, does little more in the majority of cases than train 
the patient in the open-air regime and start him on the road 
to recovery. After that he must himself make the journey 
back to assured health if he is to arrive there. If he deviates 
from the known way, relapse is likely to follow, which ex- 
perience has shown has been only too frequent. The patient 
may be so far toward a permanent arrest that he can resume 
a part or the whole of his former occupation, or undertake 
some kind of work; but he should do this only under the 
advice of his physician under whose observation he should 
remain, and by whom he should be periodically examined. 

Generally, from the force of circumstances, the "improved" 
or "arrested" case will have to return to his former occupa- 
tion, which is probably the best plan, unless the occupation 
and the environment are manifestly unhealthy; for the men- 
tal and physical strain in a familiar occupation is far less 
than in learning a new one, and the income greater. 

From his experience during treatment, the patient will 
have recognized the extreme importance of hygienic living 
and fresh air; and, therefore, he will seek to embrace every 
opportunity for obtaining fresh air day and night, and con- 

180 



AFTERCARE AND MARRIAGE l8l 

tinue to model his life upon the plan pursued while taking 
the cure. The following letter of a former patient, quoted 
by Dr. Bardswell, 1 well indicates the kind of life a cured con- 
sumptive should follow. He says: "With regard to after- 
care, I only carry on treatment in so far as the discipline and 
training of the sanatorium has made it second nature with 
me to observe certain laws. For instance, I make myself 
eat enough. In the old days I ate when I wished, and not 
much at that. I never fail to look out for fresh clean air. 
I sleep in a breeze winter and summer. I look on a draught 
as an angel from heaven. I choose open-air recreations 
rather than the theatre, etc., and always keep myself busy. 
By so doing I have no time to think of tuberculosis, but at 
the same time I never forget that I may still have got the 
damned thing in me." 

If the disease is only in the process of arrest, and yet the 
general condition is satisfactory, the patient can, not infre- 
quently, do part of a day's work, and be out of doors the rest 
of the day. For example, I have a patient in this condition 
who spends his forenoons at his business and plays golf in 
the afternoons, and thus successfully follows the "cure" and 
at the same time continues his business. All excesses should 
be avoided, whether mental or physical; the weight, appe- 
tite and strength watched, and every retogression from the 
normal standard of health must be immediately investigated. 
A bronchitis, influenza, or any respiratory disease should 
receive immediate and careful attention. 

The cardinal rules of living which the cured consumptive 
must ever bear in mind are rest, sufficient and regular nour- 
ishment, fresh air and the avoidance of excesses and over- 
exertion. Furthermore, both the physician and patient 
must not forget Osier's aphorism that "Benefit is usually a 
matter of months, complete arrest a matter of years," and 
the thesis of Brown that: "The time allotted to treatment 
is usually too short, for recovery is ever longer than onset. 
The value (possibly the results) of treatment increases as the 
square of the time ; that is, two years are four times as valu- 

1 " The Practitioner," January, 1913, London. 



1 82 PULMONARY TUBERCULOSIS 

able as one, but the struggle lasts often from diagnosis to 
death." 

Marriage and Tuberculosis 

This is a question upon which the physician is not infre- 
quently called to give his opinion, although it is not always 
followed, the patient deciding the matter from his own in- 
clination without much regard for the future. 

In the first place, should a woman who has obtained an 
arrest of the disease marry and bear children? In answer- 
ing this question, one should consider it from the standpoint 
of danger to the woman, and also that of the offspring. Will 
the latter be predisposed to tuberculosis? If the arrest of 
the disease has been maintained for two years or more, and 
the general health is satisfactory, and the conditions of life 
when married will not entail serious demands upon the 
strength, marriage can be allowed and probably there will 
be no recurrence of the disease. There should, however, be 
a sufficiently long interval between the child-bearing periods 
to permit the mother to fully recover her strength. As to 
the child, there is no reason why it should not be strong and 
healthy if carefully reared. 

If the prospective husband is an arrested case, and the 
woman is healthy, there is no reason why they should not 
marry, or why the children should not be healthy. If, how- 
ever, the husband will be obliged to support his family by 
his own efforts, it is possible that the burden may be too 
heavy and cause a recurrence of the disease. 

If the disease on the side of the man is not arrested but 
quiescent, and the general condition is good, while the wom- 
an is well, even then marriage may be acquiesced in, if the 
woman knows the facts and is willing to take the chances of 
infection, which experience has proved to be very unlikely, 
and the man the extra burdens of married life; and, again, 
the offspring may be healthy and remain so if removed or 
protected from the source of infection. 

When a husband is actively tuberculous, but the disease 
is not far advanced and the wife is strong and healthy, it 
seems to me that it is a question for them alone to decide 



AFTERCARE AND MARRIAGE 1 83 

whether they should have children, and as in the former case, 
the child may be healthy and remain so if removed from the 
father, and placed under good hygienic conditions. 

As a general proposition, no actively tuberculous woman 
should marry and bear children, for the result is generally 
disastrous. There are cases, however, in which this has 
happened, and not only has a healthy child been born, but 
neither during the pregnancy nor after it has the disease be- 
come more acute with the mother; but these are exceptional 
cases. Again, the mental effect upon a young woman who 
is tuberculous and wants to marry but feels she cannot do 
so may have a worse influence upon the disease than mar- 
riage or even pregnancy. One can also readily imagine 
cases where the tuberculous wife would be ready to take 
the grave risk of pregnancy for the sake of an offspring. If 
a woman after her marriage should be found to be tubercu- 
lous, she should be advised to avoid conception. 

Pregnancy and Tuberculosis 

When an actively tuberculous woman becomes pregnant, 
there have been varying opinions given as to what should 
be done; and different procedures have been advised for 
different stages of the pregnancy and different stages 
of the disease. No interference with pregnancy should 
be undertaken without the clearest indication that the 
condition of the wife will be benefited thereby, and the 
decision of the physician must be based solely upon the 
probable effect upon the wife. The interruption of preg- 
nancy to prevent the birth of a predisposed child is never 
justified. It is also to be remembered that the interruption 
of a pregnancy is a great shock to the system and may be 
far more injurious than to allow the pregnancy to be com- 
pleted, and unless there is a fair prospect that the life of the 
mother can be saved, or considerably prolonged, an induced 
abortion should not be done. If an interruption of the preg- 
nancy is decided upon the safest time is before the third 
month. 

Although it is true that pregnancy in an actively tubercu- 



184 PULMONARY TUBERCULOSIS 

lous woman has generally been followed, after the birth of 
the child, by an exacerbation of the disease, such is not al- 
ways the case, for occasionally pregnancy has produced 
marked and lasting improvement. On the other hand, the 
artificial termination of the pregnancy has been followed by 
an increased activity of the disease. 

The confinement of the tuberculous woman should be 
quickly terminated under anaesthesia, and, of course, lacta- 
tion should be avoided. Every effort should be made to 
support and strengthen the mother during the puerperum. 

From what has been said, it will be seen that the existence 
of pregnancy in a tuberculous wife is not always or of neces- 
sity prejudicial to the course of the disease; nor is the fact 
that the pregnant woman is tuberculous a justification in 
itself for the termination of the pregnancy. Each case 
should receive the most careful individual consideration, and 
only when one is convinced that the case is doomed if the 
pregnancy goes on, or the chances of arrest are impaired, 
should it be interrupted. Advise as we will with regard to 
the marriage of a tuberculous woman, if our advice is con- 
trary to her inclination, it will often be disregarded. 



CHAPTER XV 
CASES 

" Examples draw when precept fails, 
And sermons are less read than tales." 

Prior. 

Case I. G. B. Male, setat 45. Accountant. 

Mother died of tuberculosis at the age of 57. Generally 
well. Upon three different occasions within the last four 
months he raised a small amount of blood. He now has 
some cough with expectoration in the morning. No loss of 
weight or strength and no dyspnoea. Good appetite. His 
voice is somewhat husky. He is a healthy looking man 
weighing 155% lbs. 

Physical examination: T. 99.8 . P. 74. R. 24. 

Questionable dullness at both apices and possibly some 
roughening of respiration. Examination of sputum, posi- 
tive. 

In this case a diagnosis could not have been made from 
the slight and doubtful physical signs, but the hemorrhage 
made it practically certain even if the sputum had not been 
positive. The cough and expectoration added to the cer- 
tainty of the diagnosis. 

The prognosis is good, for the general condition is excel- 
lent and there is no constitutional disturbance. The "open- 
air" treatment for a while with later graduated exercise will 
probably produce an arrest of the disease. 

Case II. E. A. Female, setat 21. Cook. 

Father died of acute tuberculosis. Never very well up to 
17 years of age; after that stronger. Her present complaint 
is a tired feeling and headaches. Says she feels flushed in 
the afternoon. At first said she had no cough, but on ques- 

185 



1 86 PULMONARY TUBERCULOSIS 

tioning she thought she might have a little in the morning 
but no expectoration. She had lost considerable weight 
and strength, and had some shortness of breath on exertion. 
The appetite was "pretty good" and she was working. Her 
general appearance was fair. 

Physical examination : T. ioo. P. 124. R 28. 

Slight dullness at the left apex with a rough inspiratory 
sound. Some moist rales in the left base. 

The diagnosis of tuberculosis in this case depends largely 
upon the symptoms, — the increased temperature and pulse, 
the slight cough, the loss of weight and strength and dysp- 
noea upon exertion. The disease is evidently active and 
the patient needs rigorous sanatorium treatment. 

The prognosis can only be determined by the response to 
treatment. At present a guarded prognosis should be given, 
for the history is poor and the symptoms are out of propor- 
tion to the slight physical signs. 

Case III. D. F. Female, aetat 22. Shop girl. 

Family history negative : Generally well. For the last six 
months she has had a "tired feeling" and been "nervous." 
She coughs occasionally, but has no expectoration. She has 
lost weight and strength, and has some dyspnoea. Amenor- 
rhoea for four months. Appetite poor. In appearance, she 
is of medium height, thin and weak. 

Physical examination: T. 99.5 . P. 92. R. 28. 

Nothing abnormal found in the lungs. 

The above well illustrates the class of cases called "sus- 
picious" in which no definite diagnosis can be made. The 
loss of weight and strength, dyspnoea, and poor appetite 
make one strongly suspect that tuberculosis exists. Such 
cases should be kept under observation and treated on gen- 
eral "open-air" principles. 

Case IV. I. F. Female, aetat 25. 

Tuberculosis nurse. Mother died at 27 years of age from 
tuberculosis. Five years ago she had typhoid fever. Has 



CASES 187 

been feeling particularly well. A week before the consulta- 
tion she had a slight hemorrhage and subsequently streaked 
sputum. She says she has no cough, but some expectora- 
tion which, on examination, was negative. No loss of 
weight or strength, or no dyspnoea. Appetite "very good." 
Thinks she has been having a little afternoon temperature. 
Is working. She weighs 215% lbs. and looks well. 

Physical examination : T. 100.5 . P. 78. R. 18. 

Questionable dullness in the left supraclavicular space 
with somewhat rough respiration. Otherwise, negative. 

From the slight physical signs, a diagnosis could not be 
made; but the hemorrhage and increased temperature make 
the diagnosis of active tuberculosis practically certain. 

The prognosis is favorable if active treatment is at once 
instituted. The comparatively low pulse is a favorable 
omen. 

Case V. S. G. Male, setat 29. Salesman. 

Family history negative : No known exposure to the dis- 
ease; always well though never very strong. Subject to 
"head colds." Chief complaint is "getting tired." He has 
lost about five pounds in weight ; no loss of strength and no 
dyspnoea. Slight cough and expectoration. Appetite excel- 
lent. He feels able to work. In appearance he looks well 
and weighs iji%. lbs. 

Physical examination: T. 99. 2 . P. j6. R. 16. Lung 

capacity, 250 cubic inches. 

There is slight but definite dullness at the right apex and 
on deep inspiration a few fine persisting rales, both above 
and below the clavicle. 

Here the definite physical signs indicate a probable slight 
tuberculous infiltration, but the absence of any marked 
symptoms shows that there is no toxaemia. 

The prognosis is very good, and the patient need not 
necessarily be removed from his work, but kept under ob- 
servation and placed under good hygienic conditions. 



1 88 PULMONARY TUBERCULOSIS 

Case VI. T. G. Male, aetat 21. Student. 

Mother died of tuberculosis, and sister has been in the 
sanatorium with the same disease. He was at home during 
his mother's illness. Has always been well. He had a 
"cold" with intermissions for two months. The night before 
consulting his physician, he had a small hemorrhage. He 
has a slight cough with streaked sputum. No loss of weight 
or strength or no dyspnoea. Appetite pretty good. Is at- 
tending to his duties. His appearance is that of health, 
although somewhat thin. 

Physical examination: T. 99 . P. 72. R. 24. 

Slight and doubtful dullness at both apices, with possibly 
somewhat roughened respiration and prolonged expiration. 
Examination of sputum, positive. 

Here is a case in which the first definite symptom was the 
hemorrhage which was the cause of consulting his physician. 
Without the positive sputum or the hemorrhage a definite 
diagnosis could not have been made. 

A favorable prognosis was given and sanatorium advised. 
Four years and a half later he died. On account of the fam- 
ily history, a guarded prognosis should have been given. 

Case VII. J. H. Male, aetat 47. Dentist. 

Family history negative: No known exposure. Always 
fairly well. Has had more or less hoarseness and cough for 
some time. Twenty-five and again four years ago he had a 
hemorrhage. He now has a cough with expectoration, 
which is positive. He has lost ten pounds in weight, al- 
though his present weight is 178 lbs. His strength is fair 
and he does a full day's work. Some dyspnoea. The appe- 
tite is good. His appearance is that of health. 

Physical examination : T. 99 . P. 76. R. 16. 

Marked dullness over both fronts, with broncho-vesicular 
respiration, especially at the right apex. The voice is -\ — h 
and there is a moderate number of rales. The same condi- 
tion exists in the corresponding areas behind. There is 
hoarseness which is suggestive of tuberculous laryngitis. 



CASES 189 

Five months later the rales had disappeared, except above 
the left clavicle; he had gained 11 lbs., his strength had im- 
proved; the temperature range was from 97.4 to 98 . He 
had been sleeping and living in an open tent in the country, 
going to his business every day. 

The above represents a case of advanced tuberculosis of 
slight activity with little, if any, toxaemia, and where the re- 
sistance not only maintained itself but gained upon the dis- 
ease, and this in spite of strenuous daily work. Although 
such cases rarely become permanently arrested, they remain 
quiescent for long periods, and the individual not only has 
the appearance of health, but is able to follow his occupation. 
When once, however, the resistance is broken by some inter- 
current disease, such as an influenza or a sharp hemorrhage, 
for example, acute symptoms often quickly supervene and a 
fatal result follows. 

Case VIII. D. R. Male, aetat 22. Leather business. 

Father died of pulmonary and laryngeal tuberculosis, and 
he was more or less intimately associated with him. Gen- 
erally well. A well developed, muscular man, with a deep, 
full chest. Has been working in dusty places. He has had 
a cough for three or four months, with some expectoration, 
which was negative. Once he thought he had streaked spu- 
tum. No loss of weight and strength, and no dyspnoea. 
Good appetite; weight, 141 lbs. 

Physical examination: Slight increase of pitch with some- 
what roughened and possibly diminished respiration at the 
left apex; otherwise, negative. Subsequently, seven months 
later, the examination was negative and he had gained 11^2 
lbs. The Roentgen examination at this time showed no 
evidence of "acute infiltration of lung tissue," but "very 
definite peribronchial thickening together with an increase in 
the bronchial gland shadow," "the markings of the right root 
and particularly of the ascending division were abnormally 
prominent." 

In the opinion of the Roentgenologist, the plates were 
consistent with a diagnosis of early pulmonary tuberculosis. 



190 PULMONARY TUBERCULOSIS 

In this case a definite diagnosis could not be made, either 
from the symptoms, physical signs or X-ray findings. The 
weight of all the evidence, however, — the intimate associa- 
tion with his father, the continuing cough, the streaked spu- 
tum, the slight physical signs, and the X-ray picture, — all 
pointed toward an early tuberculous infection. 

The question to be decided was the future plan of life: 
Here was a young man well started in his business career. 
Should he abandon it for an out-door life, or continue in it 
under observation? Under all the circumstances, it was 
decided that the only safe course was to give up his business 
and in-door life in the city and live an out-door life in the 
country. This was accordingly done, and he went West 
upon a ranch. During the war he entered the service and 
came through without trouble. 

Case IX. J. B. Male, setat 28. Fireman. 

Family history and exposure, negative : He complained of 
a dry cough for the past two weeks and soreness across the 
chest; chilly sensations; poor appetite. 

Physical examination: T. 98.2 °. Weight, 132^ lbs. 

Dry rales throughout the chest with suspicious signs at 
the left apex. 

The diagnosis then made was chronic bronchitis with a 
question of infiltration at the left top. Twelve days later 
the examination showed many constant fine moist rales 
throughout the upper left lobe, and the X-ray plate verified 
the suspicion of infiltration at the left apex. 

This case shows how a general bronchitis may conceal an 
underlying tuberculous lesion, and emphasizes the import- 
ance of repeated examinations and continued observation 
of all cases of bronchitis. 

Case X. J. C. Male, setat 39. Inside work as stock- 
keeper. 

He is one of eleven children, of whom four have died of 
tuberculosis. He has always been well, although he is now 
about sixteen pounds under weight. His chief complaint is 
soreness in various joints, weakness, night sweats and pain 
in the left side, which, he says, "catches his wind." 



CASES 191 

Physical examination : T. 101 . P. 115. 

Dullness in the left scapular region. Two days later, there 
was marked dullness, or flatness, over the lower left lobe 
with distant bronchial respiration, and at the apex of the 
same lung, slight dullness with broncho-vesicular respiration 
and a few moist rales. The diagnosis was made of pleurisy 
with effusion, and incipient tuberculosis. The case was re- 
ported and sanatorium treatment advised. 

This case illustrates the importance of a careful examina- 
tion of the apex of the lung when there is an effusion in the 
lower half. The family history would also make one sus- 
picious of tuberculosis. 

Case XL J. T. Male, setat 31. Machinist. 

A healthy looking, well nourished man, weighing 185 lbs. 
Family history and exposure to infection, negative. Eight 
months ago some one suggested to him that he might have 
tuberculosis, and he presented himself for examination at a 
tuberculosis dispensary. From the result of the examina- 
tion, he was sent to a sanatorium. Three months later he 
was examined at another dispensary and no evidence of tu- 
berculosis was discovered. He now says that he has a slight 
cough in the morning with a little expectoration, and thinks 
he has lost some strength; no dyspnoea; appetite good. 
While at the sanatorium he was put to work. 

Physical examination: T. 98.6 . P. 88. R. 24. 

Sputum negative : Examination of the lungs negative. 

Here is a case in which there was either a slight infection, 
which was promptly arrested under sanatorium treatment, 
or in which there was a mistaken diagnosis. In such doubt- 
ful cases, either one of two courses may be followed: the 
patient may be kept under observation, or, if the symptoms 
and physical signs are suspicious, and all pointing in one di- 
rection, active treatment may be instituted; the latter is the 
safer course. 

Case XII. S. T. Female, setat 24. Married. Frail in 
appearance. 



192 PULMONARY TUBERCULOSIS 

Her husband has pulmonary and laryngeal tuberculosis. 
Has had a cough for four or five months, with expectoration 
which was negative. She has lost weight and strength and 
has some dyspnoea. She says she has twice had some hemop- 
tysis, but the record does not state how much. Appetite 
poor. Two months ago she was examined at a dispensary 
and told she had no tuberculosis. 

Physical examination: T. 98.6 . P. 88. R. 32. 

Nothing found in the lungs. 

The diagnosis of tuberculosis was made, founded wholly 
upon the symptoms and the exposure to infection through 
association with her husband. It is possible, of course, that 
the diagnosis was wrong, but with such an array of symp- 
toms, viz., loss of weight and strength, shortness of breath, 
poor appetite, and a history of hemoptysis, together with the 
exposure to infection, the diagnosis seems fully justified. 
She was advised to take active "open-air" treatment. 

Case XIII. F. S. Male, setat 19. Electrical engineer. 

A healthy appearing, well nourished young man weighing 
162 lbs. 

Family history negative : Exposure, been associated in his 
work with a man who had a cough with expectoration. Gen- 
erally well, athletic. Within the last week he has had hemop- 
tysis on three different occasions, a cupful in all, he thinks. 
He has a slight tickling in his throat and slight expectoration 
of mucus; no other symptoms. 

Physical examination: T. ioo°. P. 64. R. 14. 
Lungs negative : Expansion, 6 cm. 

The diagnosis of tuberculosis was made and sanatorium 
treatment advised; but he felt so well he did not think it was 
necessary to give up his work. 

The diagnosis in this case was made almost solely upon 
the fact of the hemoptysis, there being no constitutional 
symptoms and no physical signs. The increased tempera- 
ture was probably only temporary from the result of the 



CASES 193 

hemorrhage. The exposure to infection also strengthened 
the diagnosis. 

Case XIV. J. K. Female, aetat 22. Housewife. 

Of medium height and rather thin; weighs 126 lbs. 

Family history negative : Exposure : a "chum" of hers, she 
says, with whom she has constant association, has tubercu- 
losis. Always well. Is now four months pregnant. Four 
months ago she was in the hospital for ten days with acute 
bronchitis, she says. For the past three months she has had 
pain in the chest. Three weeks ago she was examined at a 
tuberculosis dispensary and was told she must go to a sana- 
torium. She has no cough, but sometimes a little expec- 
toration, which was negative. There is loss of flesh and 
strength, and dyspnoea. The appetite is not very good. 

Physical examination : T. 99.8 . P. 96. R. 24. 

At the left base from below the angle of the scapula, there 
were fine and medium moist rales in abundance. Otherwise, 
the lungs were negative. Day camp or sanatorium advised. 

This case is of interest for two reasons : First, is the con- 
dition at the left base a tuberculous one? "Abnormal physi- 
cal signs at the base," says Brown, "should be looked on as 
nontuberculous until definitely proved so." Considering the 
exposure to tuberculosis and the symptoms, one is inclined 
to consider this a case of tuberculosis until proved the con- 
trary. Second, especial attention should be given to all 
symptoms pointing to tuberculosis in a pregnant woman. 
When in doubt, active treatment should be established so 
that the woman may be in the best possible condition at the 
birth of her child, for experience has shown that after con- 
finement any existing tuberculous lesion is likely to become 
more active. 

Case XV. D. H. Male, aetat 26. Bookkeeper. 

Family history: Brother died of tuberculosis, and he was 
living with him at the time. Never has been ill since a child. 
Two years ago had a hemorrhage of a moderate amount, 
and a repetition of the same two months ago. Says he has 



194 PULMONARY TUBERCULOSIS 

had no other symptoms except a cold for about a week. Has 
a slight tickling cough with a very little expectoration. No 
loss of weight or strength and no dyspnoea. Appetite very 
good. Is able to work. 

Physical examination: T. 99.2 . P. 96. R. 16. 

Sputum, positive : Marked dullness over both fronts down 
to about the fourth rib. Respiration very rough. Voice +. 
A few rales at both apices. On the back in the correspond- 
ing area the same signs are found but the rales are more 
numerous, extending down to the middle of the scapula. 

Diagnosis: Advanced pulmonary tuberculosis. The strik- 
ing characteristic of the case is the extent of the pulmonary 
lesion in comparison with the almost complete absence of 
constitutional symptoms. The man does not feel ill and is 
able to work. It is a very doubtful if so extensive disease 
can ever be arrested, and so long as the equilibrium is main- 
tained between the resistance and the disease, the man is 
comparatively safe and may live indefinitely. 

As to treatment, it is probably the wisest course to at- 
tempt an arrest by the open-air cure. On the other hand, 
he may do as well to continue his occupation under good 
hygienic conditions of work and living, watching carefully 
for any break in the resistance. 

Case XVI. O. P. Male, aetat 42. Dealer in furs. 

Family history and exposure to infection, negative so far 
as known. Has worked hard since sixteen years of age and 
always been well. Six months ago he had a fracture of the 
ankle and has not felt well since. Three months ago he 
began to lose weight and strength, and had a cough and 
chills, and thinks he had some fever. He consulted a laryn- 
gologist who, from the appearance of the larynx, referred 
him for examination of the lungs. At that time there was a 
degree rise of temperature in the afternoon, a pulse of 84 and 
weight of 146 pounds. He had a troublesome cough with 
a small amount of expectoration which was positive. He 
had no appetite and had dyspnoea on exertion. He was tak- 
ing some exercise and attending to business. 



CASES 195 

Physical examination : Marked dullness at both apices with 
broncho-vesicular respiration, voice + and a few fine, moist 
rales on deep inspiration. 

Diagnosis: Moderately advanced, active tuberculosis. 

Treatment: He was put at rest in a well-ventilated room 
in his cottage by the sea-shore. At the end of two months 
the temperature was normal and there was but slight cough 
and expectoration. The weight was increasing, and there 
was general improvement in the constitutional condition. 
Two months later there were but a few sticky rales upon the 
physical examination. A year after the first examination, 
he had practically no cough, no tubercle bacilli in the spu- 
tum, and said he had not felt so well for years; weight, 156 
lbs. Meantime he had made a trip to Europe. The physi- 
cal examination was that of an arrested case. He has been 
perfectly well for the last six and a half years and all the time 
has been attending to his business. 

This case illustrates the quick response of the resistance 
to the infection under only a moderate degree of the rest and 
open-air treatment, and the permanence of the cure. Not 
every case will respond so rapidly and so perfectly. 

Case XVII. L. J. Female, aged 23. Stenographer. 
Family History: Father has inactive tuberculosis. 

Previous history: Children's diseases, mild influenza, "a 
nervous breakdown" last spring, a middle ear abscess a year 
and a half ago. Present illness : Complains of an "irritation" 
in the throat, some morning expectoration, gets tired easily. 
Slight, if any, loss of flesh. Menstruation regular. Appetite 
good. Is working. 

Physical examination shows marked dullness above the 
left clavicle and less so below. On cough moist rales at the 
left apex, front and back, with broncho-vesicular respiration. 
Apparent slight dullness at the right apex. Sputum posi- 
tive. Pulse 124. Temperature 100.2 F. 

The sanatorium was advised, but, objecting to this, she 
was placed at rest under the open-air treatment. She 



I96 PULMONARY TUBERCULOSIS 

showed marked improvement the following year, gained in 
weight, had no temperature, and took a little exercise in 
walking and housework. The pulse, however, continued 
rapid. Feeling so much better., she was tempted to resume 
work, but after a short time the disease became active again, 
and she steadily failed. 

This case is instructive as showing the disastrous results 
of attempting to resume active life before an arrest of the 
disease has taken place. Long continued rest is the price 
one must pay to obtain the arrest of an active tuberculosis. 
The nervous breakdown, as she thought it, was probably the 
beginning of the active tuberculosis, and this teaches us that 
in all 'such cases a careful examination of the lungs should 
be made. 

Case XVIII. H. D. S., aged 23. Naval officer. Family 
history negative. 

Previous history: Always well until the last 9 months, 
when he had influenza, pneumonia and empyema in the left 
lung, with rib resection. He was told he had pulmonary tuber- 
culosis and was sent to the naval sanatorium at Fort Lyon, 
where he remained for 2 months. He now comes for exami- 
nation. He is a well-nourished man weighing 165 pounds 
and has no symptoms except slight dyspnoea on exertion. 
The physical examination is negative except moderate dull- 
ness at the left base, but with a very fair respiratory murmur. 
The lung capacity is 232 cubic inches, and the chest expan- 
sion 7 cm. There is no cough or expectoration. 

It is difficult to say why a diagnosis of tuberculosis was 
made. At the present time there is only a pleural thicken- 
ing, the result of the empyema. 

Case XIX. A. S. Male, aged 22. A college graduate 
w r ho had always lived under the most favorable hygienic con- 
ditions in a suburban town. Immediate family history nega- 
tive. Xo exposure known. Xo serious illness except "ma- 
larial fever" and influenza. Three months before he was 
examined he says he contracted a cold and has been cough- 
ing with a very little expectoration ever since. Xo loss of 



CASES 197 

weight or strength or no dyspnoea. Appetite good. His 
appearance was that of a rather athletic young man. 

Physical examination : T. 98.4 . P. 108. R. 32. Weight 

146^4 lbs. 

Moderate dullness on the right extending to the fourth 
rib, with broncho-vesicular respiration and quite abundant 
moist rales on cough. Respiration roughened at the left 
apex, and somewhat diminished. Sputum positive. 

Diagnosis: Pulmonary tuberculosis. Stage II. Sana- 
torium advised. 

Prognosis: Fair. He went to the sanatorium, where he 
remained for three or four years. For the first eleven 
months he was kept absolutely at rest on account of tem- 
perature. Subsequently his temperature became normal 
and remained so. He gained in weight, the pulmonary con- 
dition improved, cough and expectoration decreased, and 
there were but few tubercle bacilli in the sputum. The con- 
stitutional condition was considered "very satisfactory," and 
he was given a limited amount of exercise. Two years after 
he first entered the sanatorium the disease was pronounced 
"arrested." After leaving the sanatorium he went up into 
the mountains, where he spent several summers and one 
winter, taking a considerable amount of exercise. His gen- 
eral health remained good, he had no rise of temperature, 
and his weight was 151^ lbs. 

Subsequently he remained at home, and soon it became 
apparent that the disease was progressing and activity had 
begun again. The whole right lung became involved, with a 
cavity above and softening below. Strength and appetite 
failed, and weight was rapidly lost, and six years after he 
was first seen he succumbed. 

This case is illustrative of many which, for a while, under 
careful treatment, progress favorably and then either from 
want of maintained resistance, or a relaxation of the strenu- 
ous sanatorium mode of life, relapse and succumb. Would 
he have recovered if he had continued indefinitely his life in 
the sanatorium? 



igS PULMONARY TUBERCULOSIS 

The case also illustrates the prognostic indication referred 
to in the chapter upon "Prognosis," viz. : that when a patient 
has lived a regular life under good hygienic conditions, good 
and sufficient food, fresh air, rest, and no excesses, and yet 
contracts tuberculosis, the prognosis is less favorable than 
with one who has been subjected to unwholesome conditons 
of life and work, for in the latter case the change to the 
"open-air" life, instituted by the treatment, with all it in- 
cludes, is far more radical and may be expected to produce 
more marked and favorable results. Again we see illus- 
trated in this case that elusive and unknown something 
which we call resistance. This patient at first developed a 
good resistance and for a while maintained it. He was un- 
able, however, to continue to do so, and the inevitable result 
followed. On the other hand, another case with the same 
amount of disease and constitutional disturbance will, under 
the same treatment, quickly and steadily develop a com- 
petent resistance and maintain it. and will obtain a complete 
and lasting recovery. The unsolved problem is to discover 
some means whereby we can produce in every case a suffi- 
cient and enduring resistance. If this is ever done, the 
treatment of tuberculosis is solved. 

Case XX. J. N. W., aged 20, was first seen upon March 
6th, 1912. He had been at school and gave a history of 
gradually failing strength, cough, night sweats and twice 
a small hemoptysis. He had been in bed for some time in 
an out-door sleeping porch. He had lost no flesh and was 
well nourished — weight 120 lbs. The temperature at the 
time of the visit in the forenoon was 99. 6°, pulse 92, respi- 
ration 20. The physical examination showed extensive ac- 
tive disease in the right lung, indicated by dullness, rough 
and diminished respiration and many moist rales front and 
back extending in the back to the base. On the left front 
there was dullness and modified respiration but no rales. 
The sputum was positive. The case was considered one of 
the third stage and an unfavorable prognosis was given. 
The usual "open-air" treatment was advised, with rest in 
bed. He was living in the country. 



CASES 199 

He was seen again on July 24, 1912. The physical exami- 
nation showed fewer rales and of a less moist nature. He 
had gained 20 lbs. and had no temperature. He had been in 
bed since the last visit. A little exercise advised. Upon 
November 7th, 1912, the examination showed improvement 
in the resonance and respiration but still quite abundant 
rales in the right lung, extending well down in front and 
back. He had gained 12 lbs. more since the last examina- 
tion. The sputum was positive. 

Upon April 21st, 1913, the rales in the right chest were 
fewer and less moist, the respiration was broncho-vesicular 
at the apex, and no evidence of moisture in the left lung. 
The general condition was excellent. Weight 150 lbs. Has 
been taking considerable exercise. 

The examination upon July 29th, 1913, was about the same 
as the previous one. On cough the rales were still quite 
abundant, and the respiration modified. The weight had 
fallen off 9 lbs. The general condition was not quite as 
good. Sanatorium advised. 

Late in the year of 1913 he went to Colorado and remained 
there several months. The record of his examination upon 
arrival there is as follows: "No trouble in the left lung; 
the right one badly involved down to the fourth rib in front 
and on the back to the base, rales both front and back being 
very coarse." 

He was not seen again until September 18th, 1916, over 
three years. At that time he appeared to be in perfect health 
and was attending school, and had been working during the 
summer. The examination showed still some dullness over 
both fronts, but with very fair and full respiration. A few 
scattered rales in the right lung; none in the left. Weight 
141 J^ lbs. 

Upon March of this year the sputum was reported posi- 
tive. The next examination was upon June 28th, 191 7. 
There was absolutely nothing abnormal, and no symptoms. 
He was at college and had engaged in athletics. Later he 
passed the physical examination for entrance into the navy 
and remained perfectly well during his service. 



200 PULMONARY TUBERCULOSIS 

This case is remarkable and unusual in that such a com- 
plete arrest should have been obtained with such extensive 
disease, within the period of five years, the restoration to 
health being so perfect that he was able to pass the rigid 
examination for entrance into the military service. Such a 
result strikingly illustrates the fact that tuberculosis can be 
arrested at any stage. It is in striking contrast to the pre- 
vious case, and well illustrates the difference in resistance. 



INDEX 

A 

Actinomycosis 81, 84 

Advance of Tuberculosis, mode of 79, 80 

Aftercare 180, 181 

Age incidence of tuberculosis 48, 49 

Air, tidal , 21 

complemental 22 

supplemental 22 

residual 22 

Albumen reaction 39 

Alcohol in etiology of tuberculosis 56 

Altitude, high, indications for 170 

contra-indications 172 

Anaemia 137 

in children 156 

Anesthesin in larygeal tuberculosis 149 

Anatomical period 27 

Anorexia 136 

treatment of 136 

Aphorisms of L. Brown 72, 107, 127 

Aretaeus Cappadox 27 

Artificial Pneumothorax 132, 133, 134 

Arsenic 137 

Asthma 83 

Atropin in hemoptysis 146 

Auenbrugger 28 

Auenbrugger's dictum 61 

Auscultation, outlines of 61, 64 

methods of 61, 64, 65 

B 

Bacilli tubercle 35, 36 

avian 36 

bovine 36 

channels of entry of 40, 41 

diagnostic value of 40, 71 

effects of gastric juice on 36 

effects of, on tissues 4 1 

how destroyed 35 

in healed lesions A 2 

20I 



202 INDEX 

Bacilli (Continued) 

morphology of 35 

examination for 37 

antiformin method of 38 

Ellerman and Erlander method of 38 

Ziehl-Nielson method of 37 

vitality of 35 

Bath, cold 118 

dangers in 118 

how to take 118 

Baillie, Matthew ( 1793) 28 

Bayle (1774-1816) 29 

Blood serum in hemoptysis 145 

Bovine bacilli in children from milk 36 

Bowditch, Dr. H. L, advice in "Young Stethoscopist" 67 

Breathing, bronchial 62, 68 

broncho-vesicular 62, 68 

cog- wheeled 69 

exercises in health 24 

rough 6y 

vesicular 62, 67 

Bronchiectasis 82, 87, 88 

Bronchitis 82, 85 

Bronchi 18 

Brown, L., Diagnostic thesis of 72, 74 

Prognostic thesis of 107, 108, 109 

Therapeutic thesis of 127, 128 

Bushnell, variations of normal sounds 95 

C 

Calcium in hemoptysis 146 

Capacity, vital of lungs 2 3 

average lung capacity for height 23 

Caseation 4 1 . A 2 

Cases of tuberculosis 185-200 

Cardiac, lesions 84 

displacement So 

Cavities 43 

Celsus 27 

Chest, bony framework of n 

alar 19 

circumference of 21 

emphysematous 19 

flat 19 

funnel-shaped 19 

increase expansion of 12 

local changes in 20 

measurements of 22, 23 

modifications of by disease 20 



INDEX 203 

Chest (Continued) 

movements in respiration 20 

pigeon breasted 19 

rachitic 19 

unilateral changes in 19 

Children, tuberculosis in 159 

physical signs in 154 

symptoms of tuberculosis in 152, 153 

diagnosis of bronchial gland tuberculosis in, 155, 156, 157, 161 

pulmonary tuberculosis in 156 

tuberculin test in 155 

X-ray in diagnosis 154 

cases of tuberculosis in 161 

Classification of tuberculosis 77>7& 

Climate, definition of 164 

beneficial results of 168 

cases suitable for change of 170 

elements of 164, 165 

factors to be considered in change of 170, 171 

favorable 170, 172 

former estimate of 166 

Climates favorable for pulmonary tuberculosis 166 

Clothing 117 

Cog-wheel breathing 69 

Complement fixation test 40 

Complications 102 

Conheim ( 1877) , 30 

Constipation, treatment of 115 

Cough 140 

diagnostic significance of 51 

in early tuberculosis 57 

prevention of rest by 112 

training to suppress 140 

treatment of 140, 141, 142 

useless 140 

Creosote, inhalation in cough 141 

Cure, definition of 100 

D 

Day's plan 125 

D'Espine Sign 154 

Dettweiler, on Climate 172 

Diaphragm, action of in respiration 13 

diminished movement of in tuberculosis 14 

Diaphragmatic respiration 13 

Diagnosis 50 

differential 81 

cases of differential diagnosis 84 to 89 

of advanced tuberculosis 79 



204 INDEX 

Diagnosis (Continued) 

Essentials of, Stoll 98 

Diagnostic Standards of Nat'l Tuberculosis Ass'n 90 

Diarrhoea, cause of in tuberculosis 139, 140 

diet in 140 

treatment of 140 

Dietetic treatment 1 14, 1 15 

in constipation 115 

in diarrhoea 140 

Diet in hemoptysis 145 

needs for special 1 14, 1 15 

in advanced cases 126 

suggestive articles of 116 

Debility in tuberculosis 136 

Diseases predisposing to tuberculosis 55 

Disinfection 177 

Dust 54 

tubercle bacilli in 35 

Dyspnoea 126, 147 

in advanced cases 147 

treatment of 147 

E 

Emphysema 19, 25 

Examination of patient, scheme of 53 

of upper respiratory tract 59 

physical 57 

position of patient in 58 

Exercise 124 

dangerous forms 117 

varieties 1 16, 1 17 

when harmful 116 

when permissible 116 

Expectoration, safe disposal of 175 

Expiration, movements of chest in 20 

mechanism of 20 

Eugenics and tuberculosis, Davenport 46 

F 

Fat, an increase of, in the diet 114 

Fever 143 

Fever, diagnostic significance of 51, 59 

absolute rest in 112, 143 

in tuberculin reaction 76 

out-door air in 143 

prognostic significance of 102 

pyramidon in 144 

Fibrosis 43 

Fibroid phthisis 44 



INDEX 



205 



Fistula-in-ano 53, 102 

Focal reaction 76 

Food, in the treatment of tuberculosis 114 

ingestion and digestion of, as a factor in prognosis 105 

milk 114 

proteins, carbohydrates, fats in 114 

suggestive articles of 116 

Framingham Demonstration 177, 178, 179 

Fremitus, tactile 69, 70 

vocal 69 

Friction sounds 63 

G 

Galen (130 A. D. ) 27 

Galloping consumption 48 

Gastro-intestinal disturbances 138 

Gee, sayings of 52, 69 

Giant cells 41 

Glands, bronchial 17, 18 

bronchial, tuberculosis of in children 153, 157 

H 

Habits, an etiological factor in tuberculosis 55, 56 

Healing, true 44 

Heliotherapy 168 

Hemoptysis, causes of 44 

artificial pneumothorax for 132 

blood pressure in 144 

dangers from 144 

diagnostic significance of 52 

diet in 145 

excessive, cause of 44 

external applications in 145, 146 

from cardiac lesion 84 

medicinal treatment of 145, 146 

cases of 149 

Hippocrates (460 B. C.) 26 

History, family 54 

past 45 

of present illness 56 

Hygiene, personal 1 19, 120 

I 

Infection, mixed 43 

ancient belief in 31 

and period of incubation 44 

exposure to 54 

primary 153 



206 



INDEX 



Infection (Continued) 

without symptoms ejo 

Influenza g 2 

Inspection of chest 58 

Insomnia 147 

treatment of 147 

Intercostal spaces 12 

artery 12 

muscles 12 

Inspiration, muscles engaged in 20 

in ordinary 20 

relation to expiration 21 

Isocrates vj 

K 

Klencke, ( 1843) 30 

Knopf, on Climate 167 

Knight, saying of 71 

Koch, Robert 32, 33 

L 

Lsennec (1781) 29 

Larynx, tuberculosis of 147, 148 

diagnosis of 147 

treatment of, general 148 

local 148, 149 

Lazarus, Riverius ( 1638) 31 

Louis ( 1827) 29 

Lindsay, general propositions 101 

Lungs 16 

boundaries of 17 

elasticity of 17 

examination of base 71 

landmarks of 18 

lobes of 17 

lymphatics of 17 

physiological difference in right apex 65 

shape of 16 

weight of 16 

Lungs, malignant disease of 81, 86, 87 

average vital capacity for height 23 

vital capacity of 21, 22, 23 

M 

Malaria 82 

Marriage of the tuberculous 182 

effects upon tuberculous woman 182, 183 



INDEX 207 

Marriage (Continued) 

if husband is tuberculous 182 

when safe after arrest 182 

Maxims and random hints 124, 125 

Milk, preparation of 114, 138 

pasteurization of 36 

Mixed infection 43 

Morphine in hemoptysis 145 

Morton, Richard ( 1689) 28 

Mountain climates 171 

Muscles of respiration 13, 20 

Musical ear, value of 66 

N 

Neurasthenia 83 

Niemeyer ( 1866) 30 

Night sweats 143, 144 

cause of 143 

false 143 

treatment of 144 

Nitrites in hemoptysis 145 

Nurse, children's, examination of 174 

O 

Occupation, in diagnosis 54 

dusty 176 

Open-air school 156 

Orthoform, in laryngeal tuberculosis 149 

Osier, his summing up 120 

Out-door life 113 

arrangements for 113 

contra-indications 113 

occupation in 114 

results attained by 114 

sleeping 113 

P 

Pain in chest 146 

treatment of 146 

Pathology of tuberculous inflammation 41, 42 

Percussion, outlines of 60, 61 

in early tuberculosis 64, 65 

technique of 65 

Pleura, function of 14 

adhesions of 14 

costal layer of 14 

lymphatics of 15 

parietal layer of - . - 14 



208 INDEX 

Pleural cavitv 



15 



interior cul-de-sac of 1$ 

Pleurisy 5& g 3 

pain in I4 6 

Pneumonia, tuberculous 47 

Pneumothorax, artificial 132, 133, 134 

duration of treatment 134 

gas embolism in 133 

indications 132 

danger in 134 

for hemoptysis 132 

importance of X-ray in .' 133 

in far-advanced cases 132 

local anesthesia in 133 

method of induction 133 

pleural adhesions in 132 

Post-mortem appearances of tuberculous lung 42, 43 

Phthisis, types of, Bayle 29 

dualistic theory of 30 

unity theory of 29 

Predisposition, acquired 45 

inherited 45 

Predisposing diseases of respiratory tract 45 

influenza 45, 55 

measles 45 

recurring bronchitis 45 

typhoid fever 55 

whooping cough 45 

Pregnancy and tuberculosis 183 

effect upon tuberculous woman 183 

effect upon the offspring 182 

interruption of 183 

treatment of 184 

Prevention of active disease from latent infection 173 

Prognosis 100 

age and sex in 105 

character and intelligence of patient in 104 

complications in 102, 103 

constitutional symptoms in 102 

factors in 100 

family predisposition in 103 

fever in 102 

final summary of 105, 106 

food in 105 

fistula-in-ano in 102 

general propositions 101 

in acute lobar and broncho-pneumonic tuberculosis, 47. 48 

in arrested disease I 8o, 181 



INDEX 209 

Prognosis (Continued) 

pregnancy in 102 

previous life and habits in 103 

pulse in 102 

temperament in 104 

prognostic thesis of L. Brown 107, 108, 109 

Prophylaxis 173 

in adults 174, 175 

in children 173, 174 

duties of physician in 177 

Psychology of tuberculous 119 

Pulse 58, 102 

R 

Rales 63, 70 

infrequency in children 154, 159 

in incipient tuberculosis 70 

localized, importance of 70 

sonorous, Dr. Bowditch on 70 

varieties of 63 

Reaction, tuberculin 

cutaneous 75 

dangers of 77 

diagnostic value of 77 

focal 70 

local 70 

Relapses 180 

dangers of .* 181 

Resistance, age of greatest 49 

age of least 49 

in prognosis 105 

Resorts, open 1 1 1, 169 

Respiration, physiology of 20 

abnormalities of 24 

in incipient tuberculosis 58, 59 

muscles engaged in 20 

bronchial 68 

Respiratory exercises 25 

Respiratory murmur, slight modifications of 69, 71 

distinctions of, in Gee 69 

Respiratory tract, upper, examination of 59 

Rest 112 

in febrile cases 112 

afebrile cases 112 

indications for 112 

technique of 1 12, 1 14 

Results of treatment, scheme 106, 107 

Ribs, movements of in respiration 11 

counting ,„,,,..,,,, 12 



2IO INDEX 

s 

Sanatorium treatment 111,112 

indications for and against in 

Sanatorium, selection of 11 1 

for children 157 

medical supervision of in 

Schedule for day's plan 125 

Scheme for recording physical signs 64 

for examination of patients 53 

Sex in prognosis 105 

Sleep, out-of-doors 1 13, 121 

prevention of by cough 112, 140 

Smoking 56 

Soldiers, examination of 93 

Spirometer, use of 21 

Sputum, examination of 37, 38, 39, 40 

disposal of 174, 175 

examination by antiformin 38 

by Ellerman and Erlander Method 38 

streaked 144 

Stages of pulmonary tuberculosis yy f 78, 70 

Stethoscope 66 

Stoll, essentials of diagnosis 98 

Strength, loss of, as symptom 51, 52 

"Suggestions and Aids" 121, 122, 123, 124, 125 

Symptoms, suspicious 51, 52 

importance of in early diagnosis 57 

Sylvius ( 1670-1672) 28 

Syphilis and tuberculosis 55 

Syphilis, pulmonary 81 

T 

Teeth, care of 115 

Temperature in children 153 

influence on by rest 112 

in tuberculin test 76 

significance of, in early tuberculosis 59, 60 

when to take 59 

Therapeutic theses (L. Brown) 127, 128 

Thorax H 

deformities of 19, 20 

Thoracic cavity 14 

lining of 14 

Tobacco 5 6 

Toxaemia 47> 111 

Trachea .....,..,., 18 



INDEX 211 

Treatment no 

climatic 164, 172 

music in 119 

tuberculin in 129, 132 

Treatment of acute miliary tuberculosis 47 

cases requiring no treatment no 

dietetic 1 14, 123, 138 

especial methods of 129 

in open resort in 

in sanatorium in 

of advanced cases 126 

of arrested cases 180, 181 

of children 156, 157 

of complications 136 

Trudeau 33, 34 

Tubercle bacilli 35 

effects of cold on 36 

of desiccation on 36 

of germicides on 35 

of heat on 36 

of^ light on 35 

in sputum 35, 36 

Tubercles, history of 41, 42 

calcification of 42 

caseation of 42 

fibrosis of 4 1 

Tuberculin, in diagnosis 75, 76, jy 

action of 13° 

in children 155 

preparation of 129 

Tuberculin, reaction 76 

cutaneous 75> 7& 

diagnostic value of 77 

dosage 76 

focal reaction 7^ 

local reaction 7^ 

results from I3 X > x 3 2 

signs of 76 

suitable cases for 13° 

technique of administration 13 1 

treatment, theory of action 13° 

Tuberculosis, acute miliary 46, 47 

Tuberculosis, acute lobar pneumonic 4& 

acute broncho-pneumonic 48 

advanced 79 

fibro-caseous 49 

in workshops l 75 

modes of advance 43 



212 INDEX 

Tuberculosis (Continued) 

old laws regarding 31 

post-mortem appearances in 42, 43 

stages of jj, 78, 79 

V 

Villemin ( 1865 ) 3° 

Virchow ( 1850) , 29 

Voice, auscultation of 69 

Vomiting after cough 139 

treatment of 139 

von Pirquet test 75, 155 

W 

Wassermann test 81 

Weight in early tuberculosis 59 

loss of as a diagnostic symptom 59 

Whispered voice 63, 69 

X 

X-ray in diagnosis 74, 75 

in adults 75 

in children 154 

Z 

Ziehl-Nielson stain 37 



THE CASE HISTORY VOLUMES 

Knowledge of the treatment of disease rests upon experi- 
ence in the treatment of actual cases. 

Lister's theory of antisepsis, based on his studies of the 
work of Pasteur, revolutionized the practice of surgery. As 
a theory it remained only an interesting study — an idea not 
taken seriously; when, however, in the wards of Glasgow 
and Edinborough Lister cured cases before regarded as in- 
curable and reduced to a minimum a great mortality be- 
fore accepted as inevitable, knowledge ripened into wisdom, 
the theory of asepsis became a known principle of treatment. 

Diphtheria antitoxin; Salvarsan; the cure of Diabetes; the 
Rational Treatment of Tuberculosis — even though based 
upon sound theory became of practical use only when they 
were tested and proved efficient in actual cases. 

Diabetes. After three years of experimental work in the 
clinical laboratories of Harvard University Dr. Frederick 
H. Allen evolved the theory, "Diabetes is a functional 
disease and, therefore, must be curable." 

Thereafter in the treatment of patients at the Rockefeller 
Institute Dr. Allen cured diabetics and in addresses and 
journal articles made known his results. Dr. Hill, physician, 
and Miss Eckman, dietitian at the Massachusetts General 
Hospital, prepared a book describing the Allen treatment, 
presenting in detail tested and proved diets to be followed, 
and including histories of cases actually treated. 

The service rendered by this little book on Diabetes, 
through successive editions, is typical of the usefulness of all 
the volumes of the Case History Series. 

Pediatrics. Dr. John Lovett Morse, Professor of Diseases 
of Children at Harvard and Physician to the Children's Hos- 
pital, selected from his records of actual cases treated those 
showing the solution of problems which confront families 
and physicians in general practice. The whole series was 
classified and indexed for ready reference, to give, the 
reader the benefit of the author's experience, as though Dr. 
Morse had himself been called in as a consultant. The value 
of the book was enhanced when Dr. Morse prepared each 
new edition — adding cases until the volume was double its 
original size and prefacing the actual case histories with 
a chapter on the Normal Growth and Methods of Examina- 



tion of lntants and Children, giving the most valuable work 
on Diseases of Children ever made for physicians and all to 
whom the care of children is given. 

Obstetrics. Dr. DeNormandie from his experience as a 
teacher at the Harvard Medical School, and physician at 
the Boston Lying-in Hospital, and as a practitioner and 
consultant, selected, classified, described and discussed sev- 
enty-six actual case histories representing the practice of 
Obstetrics. From the Hygiene of Pregnancy to the New- 
born Child no subject is omitted, and no circumstance or 
difficulty which the family and family physician meet, 
slighted. Dr. DeNormandie has given a complete account 
of the actual Practice of Obstetrics, set forth in actual cases. 

Gynecology. Dr. Charles M. Green, whose reputation as 
a teacher, physician, surgeon and consultant is unquestioned, 
has summed up the wisdom gained through years of practice, 
in his "Diseases of Women," in which his subject is pre- 
sented in one hundred and seventy-three actual case histories, 
with Diagnosis, Treatment and Result. Each case is fol- 
lowed by the author's "comments" and discussion of similar 
conditions in other cases. The cases are classified according 
to the epochs of woman's life into five main divisions : Infancy 
and Childhood, Adolescence, Maturity, the Menopause, and 
Old Age. A very complete index insures ready reference to 
the wealth of practical information which the book contains. 
A Second edition has enabled Dr. Green to revise and make 
many valuable additions to his work. 

Medicine. Dr. Richard Cabot adopted early with his 
classes the Case History plan of teaching, and his small 
textbook was revised and enlarged until in the preface to the 
present Third Edition Dr. Cabot could say, "In the present 
edition I am less limited as to space and have, therefore, 
gone into the details of prognosis and treatment — what the 
patient and his family want — more thoroughly." This vol- 
ume now, in one hundred case histories, selected, classified, 
and discussed, with questions and answers, presents such a 
resume of actual practice as is given in no other volume. 

Surgery. With a literary style unsurpassed by any med- 
ical writer, Dr. James G. Mumford gave to the Profession, 
in actual case histories, his book "One Hundred Surgical 
Problems." Written by one who was a general physician 



before he was especially a surgeon, the book portrays faith- 
fully and graphically the surgical problems of the general 
practitioner. Each case history is a drama in which the 
persons are doctor and patient. The sound surgical teach- 
ing of the book is presented in style so readable, so unfail- 
ingly interesting that Dr. Mumford's work well deserves 
its fame as a medical classic with a unique place in gen- 
eral literature. 

Diseases of the Nervous System. This subject, one of the 
most difficult for students and baffling to physicians, Dr. 
E. W. Taylor, one of the leading teachers at the Harvard 
Medical School, has presented for both students and practi- 
tioners in one hundred and fourteen actual case histories. 
After a brief Introduction under the title "Diagnostic Meth- 
ods/' the selected histories are grouped to include : 
Peripheral Nerves, Spinal Cord, Brain, Conditions of Vague 
and Undetermined Pathological Basis — with a final group: 
Psychoneuroses. For each section Dr. Taylor has written, 
as he has found needful, brief anatomical introductions with 
reference to symptomatology. To many, and especially to 
intelligent patients and families, Dr. Taylor's book is the 
only readable and clearly informing book on Nervous 
Diseases. 

Dr. Southard's books, Neurosyphilis and Shell-Shock and 
Neuropsychiatric Problems. No higher tribute has been 
paid any method of presenting, for Profession and Public, 
medical subjects of vital importance, than that paid the Case 
History plan by Dr. E. E. Southard in choosing to publish 
in this form the official volumes of the Psychopathic Hos- 
pital. ? 

Carefully reviewing and selecting, then condensing, simpli- 
fying and grouping the typical and instructive from over 
2,200 actual case histories of Syphilis and the Nervous 
System, Dr. Southard has written an epoch-making book 
making clear for all a subject heretofore vaguely under- 
stood, and one in which lack of understanding had been 
fraught with fearful consequence. 

It was largely due to the study of "weak-spot" men, who 
became victims of Shell-shock, that the science of 
Nehropsychiatry was established. To the Psychiatrist the 
case histories and their discussion in Dr. Southard's compre- 
hensive book are fundamental. To the scholar, the general 



reader — to all by whom importance of the study of mental 
conditions is realized, Dr. Southard's work is a revelation 
seemingly forever impossible but for the clash and cata- 
clysm of war. 

No hig-her tribute, nor one more deserved, has been 
paid any medical author of modern times, than that paid 
Dr. Southard. No higher praise has been given in recent 
years to any medical work of deep and far-reaching public 
interest than that given this epoch-making volume. 

Tuberculosis. Because the Case History plan had been 
tested and proved of value to lay readers on the one hand 
and to the Medical Profession on the other hand, Dr. Ed- 
ward O. Otis, whose life work in the field of Tuberculosis 
is well known, has introduced typical case histories in the 
new Second Edition of his book "Pulmonary Tuberculosis," 
a book heretofore used only by medical students and Phy- 
sicians. The Case History book gives the symptoms of 
actual cases, the essential facts considered in making the 
diagnosis, the treatment actually followed and the results. 

In rewriting his book Dr. Otis constantly had in mind 
co-operation of family, patient and physician. 

Other eminent authors, realizing the advantages and the 
success of presentation in case histories, have prepared, 
from their personal experience, volumes in their special fields. 
Books for general practitioners upon the important subjects 
of Orthopedics, Diseases of the Genito-Urinary Tract, 
Diseases of the Digestive System, medical and surgical, 
Diseases of the Skin, and other subjects are now written 
or in preparation. 

As an introductory volume Dr. George Cheever Shat- 
tuck's well-known volume, "Principles of Medical Treat- 
ment," has been included in the Case History Series. A new 
edition is in preparation, revised, enlarged, with numerous 
articles on special diseases, by colleagues of the author. 

Intelligent use by physicians of the knowledge gained 
by the experience of the Leaders of the Profession, and in- 
telligent cooperation by patients and by families who may 
through these books have understanding, is the object sought 
from the beginning, now largely attained, and destined to be 
attained yet more fully as knowledge of the Case History 
volumes leads to their extended use. 



LIBRARY OF CONGRESS 



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